Monday, September 30, 2013

Voodoo Doctor

I wrote yesterday in the entry "Shrink Wrapped" about the ongoing mental health crisis and the ability of people needing mental health care outside of simply providing them with drugs to treat and in turn avoid the hard work of actually engaging with a patient and finding out the individual needs and in turn treatment(s) they may need to overcome that which ails you.

I am all for therapy, coaching, group counseling, medication or all of the above if that is what is necessary to help and in turn allow you to be productive and functioning. We cannot expect any cures as I think that was last done with Polio so don't expect the Medical Industrial Complex to do anything soon that would ostensibly put them out of work. Therapy is no different,   I left the link to the article below comments to read the very true and in fact honest appraisal as to why there is a problem with the "industry" that is mental health.

I can assure you that this field is not dying, there are more than ample Masters of Social Workers and Ph.d's in Psychology that have set up a shingle are offering what is ostensibly called "counseling." And for the record MSW's are in fact the largest single source of mental health providers in the Country (and for the record I have never met a group more idiotic and incompetent). What is dying is the insurance coverage which has large influence over who is qualified to provide help and the length of time help is provide.  Drugs are cheaper and easier and yet they still have to refer any patients to a licensed Doctor who freely gives them without consult to the referring "therapist" as that would again take time to actually understand and in turn develop a plan for same patient.  Laziness is not just a state for the "poors."

 I have personally witnessed and experienced the clearly unqualified as they use that DSM-5 manual as their dogma and bible in which to diagnose and in turn label individuals to often a life of despair, at much cheaper rates as they are definitely not covered on insurance plans, and they need to keep that shingle suspended.  So expect nothing for less. Nothing says wellness more than co-dependence. 

Again, without clear support and the belief that not all mental illnesses are the same and that one size does not fill all, we have an industry that is in need of its own therapy. There are no clear winners in this game as it affects society as a whole as we have learned in the most extreme ways recently how desperate we are to get those into a care giving situation that will provide safety and security for us all. And that won't be happening. We kick our mental health problems in the head like we kick cans down the road.

Psychotherapy’s Image Problem

Published: September 29, 2013

PROVIDENCE, R.I. — PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven’t been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy’s problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy’s practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.

Sunday, September 29, 2013

Shrink Wrapped

With the rise in gun violence and the issue centers around access to mental health it is not ironic in the least that as we enter the great time of the Obamageddon, the discussion about access to mental health would rise as well.

But not all people who are defined "mentally ill" are dangerous to others, in fact most are only harmful to themselves. And for many families access to affordable mental health options that are not just in the bottom of a pill vial is another quandary of the medical industrial complex.  The mind is a terrible thing to waste and yet we somehow think one size fits all with regards to treatment when it comes to the complex subject of mental diagnosis and health.

I had an interesting conversation with my Harvard trained Lawyer and once again he never fails to disappoint me when it comes to me going "did you learn that at Harvard?"  I was debating the issue of what it means to be unconscious versus in a coma and he saw no difference.  God I love Harvard. But in that respect I also said  Traumatic Brain injury is a Neurological disorder and can affect cognitive functions and sometimes physiological ones and in turn leads to some mental health issues, such as depression or anxiety but it is not a mental disability.  You do not become "retarded" or bi polar or become schizophrenic as a result.  We agreed to disagree, actually he has quit arguing with me as I am officially labeled "disabled" according to the ADA.  Okay then!

I don't find conventional mental health therapy at all useful.  I would prefer neuro-psychology that focuses on the cognitive processes and how to restore and rebuild the brain. Talking therapy does not work.  I do not need speech or physical therapy, I need brain challenges and games and tests that can contribute the rehabbing of the most plastic thing in our body (well for some as many have some intentional additions in that area).  But because I don't at present have insurance and in many cases even I did it would not be covered, I have had to rely on my amazing colleagues who have access to a myriad of educational tools and information they use to teach their children with learning disabilities. My favorite so far was one teacher who gave me a test, I flunked and she responded: "good you aren't Autistic."  On second thought where are those guns the NRA promised!

And this is the quandary because again even having serious depression one is considered "disabled" and who wants to find themselves ostracized and out of work as a result?  There was this article last week about the subject and why many prefer to remain in the shadows when it comes to such issues. And hence claiming it on insurance is often not done as to avoid going public and in turn the costs and burden falls on one who needs it much as anyone else with a conventional illness needs their treatments.

The stigma of Mental health is one again due to the media and the fact that we have a real problem with regards to access and in turn information.  We just take pills for all that ails us and I have written extensively about the danger in that what big pharma dispenses with cavalier egregiousness.  But then again we are a country in denial about everything. Is that a mental illness?

Lacking Rules, Insurers Balk at Paying for Intensive Psychiatric Care

Published: September 27, 2013

THE first time Melissa Morelli was taken to the hospital, she was suicidal and cutting herself, her mother says. She was just 13, and she had been transferred to a psychiatric hospital, where she stayed for more than a week. Her doctors told her mother, Cathy Morelli, that it was not safe for Melissa to go home. But the family’s health insurance carrier would not continue to pay for her to remain in the hospital.

The second time, the same thing happened. And the third and the fourth. Over the course of five months, Ms. Morelli took Melissa to the hospital roughly a dozen times, and each time the insurance company, Anthem Blue Cross, refused to pay for hospital care. “It was just a revolving door,” Ms. Morelli said.

“You had not been getting better in a significant way,” Anthem explained in one letter sent directly to Melissa, then 14, in July 2012. “It does not seem likely that doing the same thing will help you get better.”

Desperate to get help for her daughter, Ms. Morelli sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. All told, Melissa spent nearly 10 months in a hospital; she is now at home. Anthem, which would not comment on Melissa’s case, says its coverage decisions are based on medical evidence.

Melissa’s treatment did not come cheap: it ultimately cost hundreds of thousands of dollars, Ms. Morelli said. Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness.

It was not supposed to be this way. A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this over coverage by making sure insurers would cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis.

Long a priority of Senator Edward M. Kennedy of Massachusetts, it was squeezed into a bank bailout bill with the help of Christopher J. Dodd, then a Democratic senator from Connecticut, after Mr. Kennedy learned that he had brain cancer, which turned out to be fatal. The law requires larger employer-based insurance plans to cover psychiatric illnesses and substance-abuse disorders in the same way they do other illnesses.

But five years after President George W. Bush signed the law, there is widespread agreement that it has fallen short of its goal of creating parity for mental health coverage.

As enrollment in coverage under the Affordable Care Act becomes available on Tuesday, the rules underlying mental health coverage in general — for both private insurers and the new health care exchanges — are still unclear, mental-health patient advocates say, leaving patients and families to grind through the process as best they can.

DECIDING how mental illness should be treated — and at what cost — is no easy matter. Unlike some physical ailments for which there are reams of studies suggesting a relatively clear standard of care, there is often little accepted medical evidence to support the range of treatments for many mental illnesses, like schizophrenia and severe depression.

“It’s very different from the approach to a bypass procedure or a hip replacement,” said Karen Ignagni, the C.E.O. of America’s Health Insurance Plans, a trade association representing the nation’s health insurers.

At issue is not coverage for run-of-the-mill care like prescription medications for depression or a few visits with a therapist. Insurers generally cover these costs the same way they cover medications for, say, high blood pressure.

But when patients need months of residential care, for example, or meetings with a therapist several times a week, insurers balk. The insurance executives say that the medical benefits of such treatments are not clear and that the industry is essentially being asked to write a blank check.

 Mental health accounts for a small part of total health care spending — by one estimate, $113 billion annually, or less than 6 percent of the $2.6 trillion overall health care bill. But pressure is intensifying on insurers under the Affordable Care Act, which includes mental heath care as an essential benefit, because they are already trying to keep the premiums they charge for plans on the new state marketplaces as low as possible. Insurers are concerned about the potential for new costs, while patient advocates worry that mental health will be neglected.

Both sides say Washington is partly to blame. The federal government has yet to write the mental health act’s final regulations for insurance companies, leaving a crucial gap between the intent of the measure and how it actually works.

Senator Kennedy’s son, Patrick J. Kennedy, the former congressman from Rhode Island who was one of the law’s main backers, said he worried that the Obama administration had delayed the rules because officials were preoccupied with the president’s broader legislation and needed the insurance companies’ support.

President Obama “needs the private insurers to implement this law or it’s not going to work,” said Mr. Kennedy, who has talked openly about his struggles with depression and bipolar disorder. He has held hearings on mental health issues across the country to talk to patients and their families, including one earlier this year where Cathy Morelli spoke.

Insurance companies, for their part, say they would welcome final rules under the 2008 law.

“We think it may create better clarity,” said a spokeswoman for Aetna, which says it fully supports the 2008 parity law.

The administration says it will draft the rules by year-end. While the act was clear about preventing insurers from setting strict time limits on treatment, it is vague about how parity is to be achieved. The most contentious areas are intensive treatments at a doctor’s office or clinic as well as potentially lengthy hospital stays. If an insurer does not typically limit outpatient medical treatments, for example, there is debate over what standard it can then apply to outpatient therapy sessions that could go on for months, if not years. It is those kinds of details that the final rules are expected to address.

LIKE many others, Cathy Morelli fought for a child’s care outside of the courts, but some patients and their families have filed lawsuits against large insurance companies. And they cite the 2008 law.

Jonathan Denbo, the director of marketing for CBS Sports Network, filed a lawsuit against the UnitedHealth Group earlier this year. Mr. Denbo, who had generalized anxiety disorder, began seeing a therapist twice a week after his mother died. The sessions cost $250 each, according to his lawyer. Last year, UnitedHealth told him that it would no longer cover his treatment, saying he was “generally functioning quite well,” and that he should be able to manage his condition on his own or through community resources, according to the suit.

“The use of multiple weekly therapy sessions is limited to acute exacerbations of illnesses or in the context of a clinical urgent situation in order to prevent a higher level of care,” UnitedHealth said in a letter sent to Mr. Denbo.

The psychotherapist for Mr. Denbo said UnitedHealth was violating the mental health law because, under the employer’s plan, the insurer does not require prior approval of out-of-network outpatient care. Mr. Denbo declined to be interviewed for this article. He and other patients are now plaintiffs in a federal lawsuit against UnitedHealth that is seeking class-action status.

In another case from the same lawsuit, Brad Smith, a marketing associate at the Seattle subsidiary of Sysco, a food product distributor, was urged to consider residential treatment for his teenage son, who was suffering from severe depression. Last March, the young man was involuntarily hospitalized at the Eastern Idaho Regional Medical Center, where the staff recommended residential treatment.

UnitedHealth agreed but then stopped paying for the care nine days after the young man was admitted. In its letter to the boy’s parents, UnitedHealth said stopping the treatment created only “limited risk” that the teenager would return to the hospital. There is “no expectation of further improvements in the shorter term,” the letter said, suggesting that it would not pay for care that would not result in his getting better anytime soon.

Mr. Smith nonetheless continued with his son’s care and, he says, he and his former wife have spent $100,000 trying to help him.

“I’m currently way over my head in debt,” he said. He recently sold his house at a $31,000 loss. He now lives with his sister. His son came home in August, and Mr. Smith says he thinks the treatment was successful. “It was, oh my God, we’ve got this kid back,” he said.

The idea that UnitedHealth would cover care only if patients could show that their conditions were likely to worsen without it represents a clear double standard, said D. Brian Hufford, the lawyer representing plaintiffs in the UnitedHealth case.

Mr. Hufford is now seeking a preliminary injunction for some of his clients, who, like Mr. Smith, cannot afford to pay for continuing treatment.

UnitedHealth declined to comment on the lawsuit, which it is seeking to have dismissed. UnitedHealth says that it uses case managers to help patients find alternatives when it will not pay for certain treatments and that it is pushing for additional research into what treatments are effective.

Regulators have also raised concerns. In another case that is not part of a lawsuit, and which involves a young woman from California, Anthem Blue Cross cut off benefits for residential care after five days. The facility temporarily placed the woman in a conference room.

“I was very confused the whole time,” said the woman, whose parents hired an expert to help appeal the Anthem decision. An independent review, authorized under state law, found that Anthem had to cover the treatment. Anthem tried to deny the care again but was overruled.

The cost of her treatment was around $100,000. Regulators concluded that Anthem did not comply with the state’s insurance law, which is similar to the federal act. Anthem declined to comment.

Determining what the 2008 law requires “is challenging,” said Brent A. Barnhart, the director of the California Department of Managed Health Care, one of two regulators overseeing health insurance in the state.

In late June, Mr. Barnhart’s department fined the state’s largest health plan, run by Kaiser Permanente, $4 million for deficiencies that limited access to mental health care under California law. In one location, the state found a Web site that seemed to indicate members could not get care if they had a “chronic mental illness.”

“What we found was they were falling way, way short,” Mr. Barnhart said. “The fine was intended as a wake-up call.”

Kaiser, which says it is has addressed the department’s concerns, said it was in discussions with the agency about the fine.

Mr. Barnhart said he worried that other plans might also make it hard for people to get treatment. Insurers, he said, seem to continue to view mental health as “secondary to all other health.”

Guns And More Guns

That is what the NRA would like America to become, the land of the armed and guarded.  Something I visualize akin to a police state and vigilante western town of yesteryear.

There have been two articles regarding guns and children of late. The one today in the New York Times is here and it is a tough read.  Tough.  Read it.  

The article yesterday was about guns and children too but about those guns in schools where Teachers, Administrators, Custodians, Lunchroom workers are enabled and permitted to bring a piece to school to ostensibly protect your children. The children that failed to be protected in their own home with their own Guardians and Parents and were seriously injured or killed because of guns in the home.  Yes let's add another element into this formula and ensure that if a child is not killed in their own home then make that another possibility by having them killed in school by those entrusted to protect them.

I still am waiting for the article where gun toting vigilantes have somehow managed to circumvent and in turn stop a mass shooting from occurring?  Where is that story?  The one where a "good guy" with a gun managed to overtake the "bad guy" with the gun,  and in turn prevent a mass shooting?  Has anyone heard of that?  I can wait.

I tried to imagine how me having a gun in a classroom would work? I think the comment at the end of the article by the retired teacher says it all.

We are a sick nation. I am trying to figure out how we got this way.  Why are boys so prone to gun violence? The article brings up this question but poses no theories.  Why?  What exactly are parents "protecting" their children from or whom?  This fictitious nonsense I would like very much substantiated.   Standing your ground? Again what is a kid with skittles and a juice exactly doing that requires you to whip out the pistol and shoot?  Didn't share?

Guns at School? If There’s a Will, There Are Ways

Published: September 27, 2013

CLARKSVILLE, Ark. — The slim, black 9-millimeter handguns that the school superintendent David Hopkins selected for his teachers here weigh about a pound and slip easily into a pocket. Sixteen people, including the janitor and a kindergarten teacher, wear them to school every day.

Although state law prohibits guns on campus, Mr. Hopkins found a way around it.

Like rural educators who are quietly doing the same thing in a handful of other states, Mr. Hopkins has formulated a security plan that relies on a patchwork of concealed-weapons laws, special law enforcement regulations and local school board policies to arm teachers.

Without money to hire security guards for the five schools he oversees, giving teachers nearly 60 hours of training and their own guns seemed like the only reasonable, economical way to protect the 2,500 public school students in this small town in the Ozark foothills.

“Realistically, when you look at a person coming to your door right there with a firearm, you’ve got to have a plan,” Mr. Hopkins said. “If you have a better one, tell me.”

After the Newtown, Conn., rampage last December, 33 states considered new legislation aimed at arming teachers and administrators, according to an analysis by the National Conference of State Legislatures. Only 5 enacted laws that expanded the ability for public educators to arm themselves at school.

Still, some teachers and administrators around the country have carried guns for years under state or local laws that impose few restrictions on where concealed weapons can be carried.

“It’s a fairly common practice among the schools that do not have sworn officers,” said Asa Hutchinson, a former congressman and a candidate for governor in Arkansas. He recently led the National Rifle Association’s school safety initiative, which produced a 225-page report that advocated armed security officers or, in some cases, armed teachers in every public school.

Mr. Hutchinson said he recently spoke with a superintendent in Arkansas who had been carrying a firearm for 10 years. The district was among 13 in the state, including Clarksville, that have special permission to use rules designed for private security firms to arm their staff members.

Just before the school year began, the state suspended the practice temporarily after Attorney General Dustin McDaniel issued an opinion that school districts could not act as private security companies. This month, however, a state board voted to allow the districts to continue using the law until the legislature reconsiders the issue in two years.

The number of teachers who carry guns in the nation’s 99,000 public schools is impossible to calculate, school security experts, education officials and people on both sides of the gun debate agree. It is likely 10 percent or less, by some estimates, but the number is growing.

“It’s been creeping up on us without a lot of fanfare,” said Bill Bond, a school safety specialist for the National Association of Secondary School Principals.

Mr. Bond was the principal of a Paducah, Ky., high school in 1997, when a 14-year-old boy shot and killed three students and wounded five others.

Like many others, Mr. Bond says arming teachers is the wrong approach to preventing school shootings. But some educators, especially in rural districts, have been quietly carrying guns to school for years by making use of permissive state gun laws.

In Georgia and Missouri, guns can be on campus as long as they are in a locked car. In Massachusetts, Louisiana and Nevada, a teacher can carry a gun on campus with written permission from school officials.
Hawaii and New Hampshire do not have any prohibition against weapons on school property for those with concealed-carry permits

And for more than a dozen years in Utah, anyone with a permit to carry a concealed weapon can take a loaded gun to school without even telling the principal.

This year, for the first time, dozens of states have considered more formal approaches to regulating the ways educators may arm themselves. Only a few have moved ahead.

In Kansas, a law that took effect in July allows school districts to select employees with concealed-carry permits to bring guns to school. But Denise Kahler, a spokeswoman for the Kansas State Department of Education, said she was not aware of any districts that were pursuing it.

In Tennessee, where a similar law passed, insurance concerns stopped some districts from arming teachers. Lee Harrell, director of government relations, labor relations and policy for the Tennessee School Boards Association, said this week that he was not aware of any districts that were arming teachers.

The most sweeping new law is in Texas, where the Protection of Texas Children Act went into effect on Sept. 1. Teachers who want to serve as armed school marshals must have a license to carry a concealed weapon, pass a mental health evaluation and be trained specifically to respond when someone with a gun is inside a school shooting students.

The program is still being developed, and unlike the Arkansas effort, teachers would have to keep the guns under lock and key and only one school marshal would be allowed for each 400 students.

Meanwhile, in states where the laws do not prohibit teachers from carrying guns, teachers and other school personnel are seeking private training in increasing numbers.

“I think the number would shock people,” said Jim Irvine, a firearms trainer in Ohio who has taught 168 teachers to carry guns in school since he began a program specifically for educators this year.

Mr. Irvine said he knew of several districts whose teachers and administrators were armed or training to be.

“Our law has always been that it’s up to the individual school district,” he said. “It’s not new, but it’s new in popularity.”

One is the Newcomerstown Exempted Village School District, in rural eastern Ohio, where the school board in June approved a policy that allows employees who have a concealed-weapon permit and specialized training to go to school with a gun.

Part of the strategy is to keep the identities of which teachers have guns under wraps so neither students nor potential attackers will know where the guns are, so Jeff Staggs, the superintendent there, is not talking much about it.

But, he said in a recent interview, “the community feels over all that their kids are safer in the district this school year.”

Still, in Arkansas and other states, the notion of arming teachers is meeting strong resistance.

“The idea that a single relatively untrained teacher is going to bring this person who is heavily armed down is a stretch,” said Mark Glaze, the director of Mayors Against Illegal Guns. “The idea is to keep the guns from the hands of the shooter.”

Those who have spent their lives in the classroom have similar concerns.

“No teacher that I know of could ever receive enough training,” said Steve Gunter, a retired history teacher in Bentonville, Ark.

“If I had a gun in my room with some of these students where I taught? They’d get it from me and shoot me,” he said. “They’d say, ‘Mr. Gunter, you gave me an F? Here’s your F.’ ”

The Obamageddon is here

On Tuesday the Insurance Marketplace for those who need Medical Insurance opens. For those in States who  have elected to not participate in the expansion and options for Medicare I have no clue what you are going to do to find insurance options nor the credits needed to obtain insurance if you are low income.   Nothing really changes frankly but the lack of information and misinformation with regards to the dreaded Obamacare and in turn its application is what is being used to extort, threaten, coerce, blackmail or whatever you feel appropriate the Republicans in Congress to shut down the Government.  Okay then.

The article below discusses the confusion, the need and the resistance by those of many ages and incomes with regards to the new mandate and choice options available. As I wrote about in Choose Wisely, this will be the most confusing and of course opportunity for further graft and extortion by third parties in their attempt to make money from individuals and their need for proper medical care and ways to offset the never ending costs that seem to rise regardless of the economy.  As I have often speculated any other industry that puts such a significant amount of Citizens into bankruptcy as medical debt does would have been placed under Congressional investigation and oversight has over the years been literally given a pass.  From bills to eliminate the debt from being placed on credit reports, to balance billing to other consumer related legislation, when it comes to the lobbying power of the Medical Industrial Complex, even the Defense contractors could take a lesson.

Its funny however that in the current standoff in Congress about Obamacare there is actually more bills and other legislation issues that of course go out of their way to stop American consumers any protection from the Medical Industrial Complex, including more Medical Tort reform to reduce Malpractice suits or perhaps actually address it as it really is with over 100,000 injuries a year related to medical malpractice, a more realistic approach, as always from the torch bearer, California.

And of course the Keystone Pipeline is another element to the blackmail or extortion that is tied to our Budget crisis. Nothing says a system more broken tying Energy, destruction of the environment and of course money to health care and the need to keep America running on time and on "budget."

Funny how the Congressional dipshits love to use micro terminology and application to macro economic problems.  Well then think of it as this - America had a bad car accident and now has millions of dollars in hospital bills.  Should we file bankruptcy? Get a loan? Or get credit?

On the Threshold of Obamacare, Warily

Published: September 28, 2013

The insurance marketplaces that form the centerpiece of President Obama’s health care law are scheduled to open on Tuesday, a watershed moment for the Obama administration, but also a crucial turning point for millions of Americans who will finally get the chance to square the law’s lofty ambitions with their own personal needs.

While some people desperate for coverage will need no persuading to sign up, for others the decision will amount to a series of complicated calculations that would challenge an accounting whiz, let alone an ordinary human: Are the new plans less expensive or more generous than existing ones? How do premiums and out-of-pocket costs compare? Are the networks of doctors and hospitals the most desirable? Who qualifies for how much of a subsidy, and what is the tax penalty for a miscalculation?

How millions of people answer these questions over the next six months will be vital to determining whether the Affordable Care Act lives up to its name and its ambitious goal of helping more people buy the coverage they need.

Much is at stake for insurers as well: they must attract enough healthy people to pay for the care of sicker patients and price their offerings to keep premiums low enough to be competitive but high enough to be sustainable.

Health insurance “is a very complex product,” said Lynn Quincy, a senior health policy analyst for Consumers Union in Washington. “It is going to be more complex this time around because things are changing, and people are confused about the changes.”

As the state insurance exchanges are set to open, we talked to people around the country who will be among the first to give them a test drive. For some, the law could provide welcome relief from mounting medical bills; for others, a break from rising premiums. Still others must decide whether insurance is right for them at all.

Mitchell McGovern, 26, lives in Brooklyn and works as a part-time sales associate at a Crate and Barrel store in Manhattan. He earns about $15,000 a year and does not have health insurance of any kind.

A bout with pneumonia in January sent him to the doctor’s office, which cost him $75, and $150 for medication. Mr. McGovern said he would love to buy health insurance — and he was mindful that the law requires him to do so — but only if it cost him less than $100 a month. “I live paycheck to paycheck,” he explained.

Mr. McGovern is exactly the sort of person the Obama administration needs to enroll in the new insurance marketplaces if the federal health care law is to succeed — young, healthy people who until now have not been covered by insurance, either because they couldn’t afford it or because it wasn’t a priority. If a critical mass of these people doesn’t enroll — the federal government hopes to sign up about 2.7 million of them — the premiums for plans offered on the exchanges could skyrocket and cause the market to fail as fewer and fewer people take part.

Mr. McGovern’s current income will probably qualify him, just barely, for Medicaid in New York State. But for Mr. McGovern and others like him, predicting how much he will make even a few months from now is hard, and he may end up qualifying instead for tax-credit subsidies in the state marketplace. Mr. McGovern recently moved to New York from California and sees his job at Crate and Barrel as a foothold until he finds work that would offer more money and perhaps coverage paid largely by the employer.

His uncertain financial situation is typical of the population most likely to consider the insurance marketplaces, said Ceci Connolly, managing director of the Health Research Institute at PricewaterhouseCoopers. Only about 51 percent will have full-time jobs, with a median annual income of about $21,700, according to an analysis by her firm based on government data like the census. She said 38 percent of the people expected to enroll will end up shuttling several times between Medicaid and the marketplaces over the next four years.

Most of those who are expected to sign up for insurance in the marketplaces — 91 percent, according to PriceWaterhouseCoopers — consider themselves in relatively good health. That would be good news for insurers and others who have an interest in seeing the law succeed. But Ms. Connolly cautioned that this assessment, which is based on federal surveys of uninsured people, might be a bit optimistic, given that many in this group have not recently visited a doctor.

“We certainly suspect that some of these individuals could have some potential health conditions percolating that they’re not yet aware of,” Ms. Connolly said.

‘I’m Not Invincible’

Lavel D. White is also 26 and getting by without health insurance. Unlike Mr. McGovern, however, he knows he has a health issue. A documentary filmmaker who lives in Louisville, Ky., he has high blood pressure. But, he said, he has to pay out of pocket for doctor visits and sometimes doesn’t refill his medicine because he doesn’t have insurance.

To help millions of low-income Americans afford coverage, the law created subsidies that can bring down the cost of a policy. The most expensive plans, at the platinum level, will limit the amount people have to pay toward a doctor’s bill or a hospital stay, while the least-expensive bronze plans may require significant out-of-pocket spending. Under federal law, all plans cap the annual amount that someone must pay for care at $6,350.

Without insurance, Lavel White, 26, sometimes doesn’t have a medication refilled.

The Obama administration has estimated that a 27-year-old with an income of $25,000 will be eligible for a silver plan, a moderately priced policy, for $145 a month.

Mr. White said he had researched his options for enrolling and found them reasonable. His income varies — last year, he made about $11,000, and this year he expects to make around $16,000. He will be eligible for Medicaid if he earns less than $16,000, but if he makes about $20,000, he will pay about $67 a month for the second-least-expensive silver plan offered in Kentucky. All insurance plans offered in the marketplace must cover Mr. White’s preventive care, but how much his medication will cost will depend on the details of the version he selects.

“I know there’s a need for me to be healthy and to be insured, but I haven’t felt like I’m sick,” Mr. White said. He said he planned to examine his options closely but was still not sure whether he would sign up. “I know I’m not invincible and I am eventually going to get sick.”

The Cancer Survivor

Five years ago, Jenifer Vogt was treated for thyroid cancer. She then had insurance through her employer, but she now works for herself, as a freelance arts writer without insurance. Premiums for private health coverage have been too high.

Ms. Vogt, who is 44 and lives in Boca Raton, Fla., knows she needs insurance and is eager to sign up in the state marketplace. “You really can’t live without it,” she said. She skipped a recent scan to check if the cancer had returned because, she said, she couldn’t afford it.

Ms. Vogt does not know whether she is eligible for a subsidy. She said she could afford a policy costing $500 a month and would be willing to pay as much as $700, even if it meant sacrifices like eating out less often. She hopes she can find a policy in that range in the Florida marketplace.

Another concern is whether the plans being offered will include her doctors. “Because I’m a cancer survivor, I have really good relationships with my doctors here,” she said.

But she would sacrifice even those relationships to get health coverage at this point. If the Florida options prove unaffordable, she said, she’d consider moving back to New York, where she once lived, or working for a company offering insurance rather than working for herself if it was the only way to get coverage.

“I live with that constant fear if I go out tomorrow and have an accident, I’m going to lose everything,” she said. “I would completely go bankrupt.”

Drug-Cost Questions

Anne Villanueva of Seattle has a different set of questions but, like Ms. Vogt, no easy answers. Ms. Villanueva, 27, works as a freelance transcriber and sells pillows and hair accessories on the Web site She recently learned that her insurance company would terminate at year-end the plan she now buys privately. The options that the insurer offered instead come with higher deductibles — $6,350 rather than $3,500 — and less generous drug coverage.

Ms. Villanueva takes the drug Enbrel for rheumatoid arthritis; the drug, though costly, is paid for through an assistance program run by Amgen, its manufacturer. That program also covers her current deductible.

She is leaning toward buying insurance under Washington State’s marketplace because she thinks that the out-of-pocket costs will be lower. But it is still unclear how drug companies like Amgen will cover patients’ drug costs in the marketplaces.

The federal Department of Health and Human Services is still determining whether the marketplaces should be considered federal programs; if they are, drug assistance programs could be characterized as government kickbacks and rendered illegal. The drug companies could indirectly cover patients’ costs through nonprofit foundations, but those details have not been worked out.

“I don’t know what I’m going to do if I don’t find something better,” she said. “I’m still freaking out, but I’m also slightly excited to see what the health insurance exchange is going to be like, and what it’s going to offer me.”

The Over-50 Quandary

Gary and Susan Smith are also seeking lower insurance costs by shopping in a state marketplace. The Smiths, who own a small engineering consulting business in Wise, Va., in the state’s coal-mining country, have seen their costs grow to more than $3,000 a month from $1,100 a month four years ago.

People in their 50s and 60s are often charged very high premiums because of their age. And although Mr. Smith, 58, said he is generally in good health, he noted that he has “a little” arthritis and high blood pressure.

Mr. Smith said he was skeptical of the health care law and didn’t trust Republicans or Democrats in Washington. “Nobody can tell me what it’s going to do,” he said. “What I’m hearing is I may not be able to keep my doctor.” But based on the research he has done, he said, “I know we’re going to get a rate less than what we’re getting now.”

Jesus and Soila Cantu have been looking forward to the new law. “I was trying to get some insurance when all this happened,” Mr. Cantu said. It has been years since Mr. Cantu, 55 and an independent contractor in El Campo, Tex., had coverage. His wife, 63, who was a teacher’s aide, lost her insurance when the school district eliminated her job and she worked as a substitute instead
Soila and Jesus Cantu of Texas are eager to enroll. Mrs. Cantu has leukemia, and the hospital bill at the end of August was $650,000.

Last summer, Ms. Cantu had double vision and trouble focusing. After going to various doctors, whom the Cantus paid themselves, Ms. Cantu received a diagnosis of an aggressive form of leukemia. She eventually went to the M. D. Anderson Cancer Center in Houston, where she has been treated for more than two months. The bill at the end of August was $650,000. The hospital, he said, called them to ask for a payment for $500,000.

“Are you kidding me?” Mr. Cantu recalled telling the hospital representative. “I don’t have that kind of money lying around. The best I can do is $5,000.” He told the hospital he would try to pay that amount every month.

Before his wife’s cancer diagnosis, the Cantus were financially comfortable, and they believe they make too much money to qualify for any assistance. Now they are deeply in debt because of the cost of Ms. Cantu’s care. Mr. Cantu said he had been waiting to enroll in the health care marketplace. “I wanted to get us prepared for Obamacare and I didn’t want to pay a fine.”

But while Mr. Cantu expects to enroll for coverage for next year, the law won’t help him with his wife’s medical bills, which he estimates now approach $1 million, if not more. “Where am I going to get that kind of money?” he said. “In 20 years, I wouldn’t be able to pay it off.”

Saturday, September 28, 2013

And so it goes, on and on

I was invited Monday to the Consumers Union Patient Advocacy meeting here in Seattle. They are working towards legislation with regards to medical devices and full transparency and other related factors in that area.  There is a free lunch and I love to go to anything with free food but after last week's conference I attended, I am sure that there is no such thing as a free lunch.

I went to the Harborview Hospital and in turn University of Washington's Trauma Conference.  It was covering the major issues surrounding Trauma, as they are the monopoly, whoops I mean sole provider of Trauma care for 5 States (including Washington).  It was interesting to listen to them brag and posture over their "standard of care" their protocols and their level of engagement in the community including writing laws that specifically were about Traumatic Brain Injury. 

I sat there incredulous and amazed frankly at the duplicity and utter grandiosity from which each UW Presenter spoke.  I wondered if they cared at all about any Patient, while professing such concern that each case was different. 

I found two other cases that I would have very much liked to address to them, perhaps next year. 

The first case was a couple of years ago.   A mentally ill man ax murdered a man in front of several witnesses. He was arrested immediately.  What many did not know was that in fact the day previously he had done the same. 

A homeless man accused of killing a stranger with a hatchet in Seattle's Capitol Hill Neighborhood is a suspect in another homicide investigation, according to charging documents released Tuesday.
Michael LaRosa, 26, was charged with first-degree murder on Tuesday for an attack on Nov. 22 in which he struck Joseph LaMagno, 58, with a hatchet and killed him, the documents stated. Those documents also said LaRosa is a suspect in a homicide that occurred 24 hours earlier in the International District.

Seattle police officers responded to a call of a man who was down on the ground suffering from a head wound at 5th Ave. S. and S. Weller St. around 8:40 p.m. on Nov. 21. 

Seattle Fire Department medics were already on the scene treating the unresponsive 64-year-old man who was bleeding profusely from the head. It appeared initially that the injury may be been caused when the man fell, striking his head against a metal pipe attached to the building. 

The victim was transported to Harborview Medical Center with life-threatening injuries. Police also began investigating the case as a possible assault. An autopsy that was performed on the man who died Friday determined that he more injuries than originally reported and that his injuries were not consistent with a fall, but with a serious assault.
The victim, Dale Richard Holme, was homeless and struggled with dementia, prosecutors said. He stayed frequently at the Union Gospel Mission shelter about four blocks from where he was found.

Really? Did anyone actually believe a pipe killed this man or the fact that this man was nothing so why bother.   He was homeless had a history of mental illness and in this case not worth caring about.  Had the actual perpetrator not admitted to doing this his death would have been due to a fall.  Harborview crackerjack squad there not recognizing an ax wound versus that from a fall on a pipe... really?

Then we have this case from just last week:

A video of the 33-year-old man beaten in Belltown has been released by Seattle police, who hope someone can identify people he was talking with.

Rory Burks, 33, suffered serious injuries Monday and is still at Harborview Medical Center, where family said he has damage to the front of his brain. Burks’ mother said her son was attacked from behind as he left a wedding reception in Belltown about 1:30 a.m. last Monday.

“He's just terrified that they're coming back,” she said.

Police found surveillance video of the victim talking with two men and a woman during the evening, and police are now hoping to speak with the trio. Detectives have not yet identified the trio and released the video Tuesday afternoon.

Seattle police have said they’re not sure if Burks was attacked.

“Unfortunately, we don't have anything that says yes, this was definitively an attack,” Detective Mark Jamieson said.

KIRO 7 asked if Seattle police believe it was an accident.
We've had cases like that before where people have fallen, struck their head and ended up in the hospital,” Jamieson said.

Detectives believe Burks was with his friends in the wedding party until about 1:30 a.m. Monday when he left a hotel at Fourth Avenue and Stewart Street.

The man and a group of friends, who were all wearing matching tuxedos, had planned to go to a bar, but he never arrived at the bar. The man’s friends apparently did not realize he was missing.

After the bar closed at 2:30 a.m., the wedding party was walking back to their hotel when the Medic who drove Burks  stopped them and said he had just transported a man, who was found unconscious, hurt and wearing a tuxedo, to Harborview.

“If people saw the victim around Fourth and Blanchard … we would very much like to talk to them,” Jamieson said.

Coast Guard friends said they have setup a medical support fund for Burks, who is covered by his mother's insurance for another three months.

And then there is the third story: Mine.  I have posted it many times here and it is on the Pro Publica blog regarding Patient Safety.  But I too believe I was a victim but my right to face the boy I believe tried to hurt me and in turn let me hurt myself walks free.  And yet I had ID and Insurance and was not homeless, and I was ignored as if I was (which should not matter), my medical care for my injuries neglected and ill treated.  No protocol, no standard of care, no pats on the back by a Medical team of a job well done. No I was thrown in the street like an animal who was an inconvenience to the hospital.

I wrote the Attorney who is defending my Malpractice suit a letter telling him about my experience at the Conference and I have put an excerpt below.  I am done with my story but I am not done with my quest to find out why or at least get the respect I did not get February 8th, 2012 by the staff at Harborview Hospital and UW Physicians who failed me in every way.

Three victims, three similar stories, three different endings for the same injury. Interesting. Consistency is the calling card there!  So much for the concept “standard of care.”  Maybe it depends on the Medic/Police escort. 

I can’t wait until next year’s conference.  I would love the opportunity to speak of the miracle on how I survived - Harborview. Compared to the “belief” that I was date rape drugged (as that it will all it can ever be), the alcohol poisoning, possibly being raped, the car crash resulting in full respiratory arrest and traumatic brain injury seems pale in comparison to my eviction to a person unknown and wandering the streets after a mere 72 hours in Harborview – 48 after ventilation removal.  And then with little to no Medical support or treatment, within a year of injury, invited by a member of the very staff of Harborview to sue and in turn becoming a Pro Se Plaintiff in a lawsuit against the same hosts of the Conference, all while recovering from a serious Traumatic Brain Injury! This should be the keynote speech!  

And why the lawsuit?  All to seek the truth and Justice ultimately denied me, not to mention some form dignity and acknowledgement of failure to treat me appropriately for the injuries in which I was admitted.

Someone told me that I need to move on and forward. No one would love to do that more than I. My health is precious, the resources I have to do so are slight but equally important.  I don't have a fund or friends or support network. I go alone as I did that night as I have always done so.  I go alone.  Perhaps that it is why I won't be at the Conference Monday, I can't be where I don't belong.

Friday, September 27, 2013

Blue Sky's For You, Me, Anyone

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The have just introduced their first Unisex line of scrub uniforms and still with the blue sky comfort and function for which they are known. These new uniforms promote a feeling of relaxation and high-quality, luxurious comfort.  And the best part is they are available individually or as sets.

They are high tech, cutting edged and highly functional with room for cell phones or other medical instruments or electronics.   They work well with any of the other lines of uniforms, lab coats and jackets and other accessories you may need on the job or even at home.  They are that comfortable to wear anywhere.

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Three, Four or More Company

I have been collecting and reading more into the concept that I call the "New Commun-ty" or what has been called communal or now co-housing.

And a week ago I read about these golden girls sharing a residence and the pitfalls and the pleasures of what it means to build a family that lives and cares for the members regardless of the presence of DNA or license.

I do believe that this is a very approachable sense of living. With car sharing, to tool sharing to couch surfing, this new generation seems to have no problems with the idea that what is mine is yours too.

I laugh at the 70s sitcom Three's Company and the retro way that 2 girls and a boy had to share an apartment but to do so the man had to be gay to appease the landlords lest he think something was up. It seems rather quaint today. But then that was then and this is today. The commune of yesteryear has its own interesting perspectives, but these ladies do show how it can work in today's times.

Till Death (or Decorating Disputes) Do Us Part By ELAINE LOUIE
Published: September 18, 2013

Mendocino County, Calif. — Twenty years after they embarked on an experiment in communal living, the members of Cheesecake gathered for an anniversary celebration over Labor Day weekend. Nearly 100 people — the seven who live here full time, six who are here part time, and assorted children, grandchildren and friends, including Laura Hartman, one of the architects who designed the complex — spent two days barbecuing, talking, hiking through the redwoods and competing to see who could bake the best cheesecake. (The competition was in honor of the community’s name, which is derived from a loose translation of Casada, the surname of the family who owned the 20-acre property at the turn of the 19th century.)

The younger and more adventurous among them slept in tents or tepees in the meadow (Ms. Hartman brought her own pup tent), while older visitors bunked together in the residential buildings or stayed in hotels nearby.

It was a fittingly multigenerational celebration for an idea inspired by the parents of some of the original members, who became increasingly isolated with age: no one should have to grow old alone.

In 1994, The New York Times reported on how those members, or “partners,” as they called themselves, had settled into their first year of life as a community (“Retirement? For 11 Friends, It’s Off to Camp”). It was one of a number of such experiments, known as cohousing communities, that were springing up around the country at the time, based on a Danish model developed in the 1960s.

The original group of 11 included four married couples and three women, all in their 50s and 60s, each of whom agreed to pay a monthly fee for the mortgage, taxes and insurance on the 6,000-square-foot complex, as well as a small daily usage charge for utilities whenever they were in residence (food and phone bills were handled individually). Bedrooms and some bathrooms were private, but nearly everything else was shared, an arrangement that seemed feasible given the longstanding friendships of most of the members, who had started a cooperative nursery school for their children when they lived in Southern California in the 1960s. Still, there were three buildings in the complex (two that contained common areas and private apartments and one where residents could pursue their hobbies), because, as Ms. Hartman said in the 1994 article, “Everyone under one roof made people nervous.”

How did the experiment turn out? On the 20th anniversary, the consensus was generally positive.

As Helen Papke, 84, observed, it has been a lesson in patience. “When it’s good, it’s so good,” she said. “And when it’s bad, it’s so bad, the angst and argument we have with each other. But we have a conviction to work it out — and we will.”

Dick Browning, 78, whose wife, Louise, died in 2007, was more effusive. “I love it,” he said. “I love the community.”

Of the original 11 members, seven are still here, although apart from Ms. Browning, no one has died. (One couple and one woman left for personal reasons.) The community has taken on new members, so there are now 13 altogether.

No one seems lonely, but some of the residents aren’t quite as energetic as they once were. Take Daniel Myers, a retired lawyer who moved in with his wife, Jill, in 1993, when he was 60. Now, he said, “I can’t get on the roof to get the leaves off, and I can’t chop wood.”

And needless to say, there have been plenty of compromises along the way. Even something as simple as cutting down a tree or buying a new dishwasher requires a consensus, or at least the agreement of three-quarters of the residents. And getting that many people to agree on anything can take a while.

Ask Sophie Otis, a clinical psychologist who is now 77, who had to lobby for almost two decades to get rid of the tree obstructing the view from her window. In 1993, when she moved in, it was only six feet tall and she could see around it. Ten years later, at 30 feet, it was starting to block the light. But it wasn’t until January, when it was 45 feet tall and threatening to fall down, that the community agreed to remove it, Ms. Otis said.

“They finally cut it down this year, not because of my problem with the view,” she said, “but because it was blocking the light and was a hazard in lots of ways.”

In matters involving the environment, Ms. Otis said, the community is divided into two camps: “Some are Druids, those who don’t want to change anything, and some are foresters, who can cut the brush back. Jill and Gaile are the Druids.”

Gaile Wakeman, a retired pediatric physical therapist who is 76, concurred. “I don’t want a single tree to be cut,” she said. “I don’t give on this. You cannot replace a tree that’s been here 300 years.”

Or as Mr. Myers said, “When you think about taking down a tree, we’ll have a fuss over it.”

The other thing residents tend to disagree about is money. And as is true elsewhere in the country, Ms. Otis said, “conservatives are those who do not want to spend money, and liberals do.”

But while these distinctions may resemble those between Republicans and Democrats, Ms. Wakeman noted, Cheesecake members lean to the left politically. “We’re all pretty liberal,” she said. “A Tea Party person would never live here.”

Most of the rules they established at the outset remain in place. Private quarters may be decorated according to personal tastes, but in communal spaces the majority taste rules. No one can inherit a membership in Cheesecake; members’ children must apply to join the group like anyone else. And these days, buying in to the community costs about $25,000 upfront, plus a continuing $500 monthly fee and an $11 daily charge for food staples, electricity and Internet use.

But time and infirmity have altered at least one rule.

Initially, members agreed that if one of them became seriously ill, he or she would have to go elsewhere for care, because Cheesecake wasn’t designed to function as a hospital or hospice. But when Ms. Browning, a retired school administrator, had open-heart surgery in 2003 and learned she had cancer the following year, the group changed its collective mind.

During the four years she was sick, when she wasn’t in the hospital or at her son Jonathan’s home in San Francisco, she was at Cheesecake. And when Mr. Browning, a retired school principal, brought his wife back after her 2003 surgery, residents began appearing at the Brownings’ door within the hour, he said: “They asked, ‘Can I be the one to bring tea to you?’ ‘Can I bring flowers every day?’ ”

After his wife died, he said: “I’d be in my room, grieving and crying. But I wasn’t alone.”

Cheesecake was envisioned for happier times, but for some of its residents it also seems to have made the difficult ones more bearable. As Marco Heithaus, the spouse of the Brownings’ son Jonathan, said: “When you lose a person, usually you grieve for a year or two. But there was so much support, Dick came out of his shell in six months.”

The New Normal

This is the new economy. The middle class can now be called the working class and we can eliminate that concept as it is slowly eradicating like our shores to global warming. Another fact that seems to be in permanent denial as we do nothing about that either.

The reality is wages and incomes are stagnating unless you are a member of the privileged class of the 10%. Now within that group they do have an upper, middle and lower income strata with the upper 1% taking home the largest percentage of income leaving the other 9% to assume the mantel of what was once the "middle class."

That issue is subject of the new documentary with Robert Reich called "Inequality for All". Mr. Reich was on Bill Moyers & Company this weekend discussing the film and the concerns that we are now relying on the robber barons and those they have entrenched in Congress to fix a problem that to the robber barons is not a problem. So in other words, if it ain't broke don't fix it.

Add to the point that it is almost a derogatory term to be considered middle class but those that do self identify as such are simply calling a duck a goose and a duck by any other name is still a duck. An interesting article here discusses the quandary we have when it comes to quacking whoops I mean investing and planning for the future.

The Quality of Jobs: The New Normal and the Old Normal

September 20, 2013, 12:01 am 32 Comments

Since the Great Recession of 2008-9, the labor market has recovered at an agonizingly slow pace. Despite 42 consecutive months of gains in private-sector employment, the unemployment rate is still at 7.3 percent; in December 2007 it was only 4.6 percent. The current unemployment rate is higher now than in 2007 across all age, education, occupation, gender and ethnic groups.

That’s despite the fact that about four million workers have left the labor force, driving the labor force participation rate to a historic low, at least a percentage point below its long-run (downward) trend, according to the Council of Economic Advisers.

Both hiring and quit rates remain significantly below their pre-recession peaks. Although the share of the long-term unemployed has fallen from its peak of 45 percent in 2011 to 38 percent today, it is still far above its 2001-7 average. And about eight million people are working part-time for “economic reasons,” a euphemism for those who would like a full-time position but cannot find one.

The weakness of the labor market is manifest not only in the number of jobs created and the number of unemployed but also in the quality of jobs. Here the news is also bleak.
During the recession, employment declined across the board, but 60 percent of the net job losses occurred in middle-income occupations with median hourly wages of $13.84 to $21.13. In contrast, these occupations have accounted for less than a quarter of the net job gains in the recovery, while low-wage occupations with median hourly wages of $7.69 to $13.83 have accounted for more than half of these gains. Over the last year, more than 40 percent of job growth has been in low-paying sectors including retail, leisure/hospitality (hotels and restaurants) and temporary help agencies. Many of these jobs are not only low-wage but also part-time for economic reasons.

According to a recent analysis at the Federal Reserve Bank of Atlanta, low-wage jobs usually account for 40 to 50 percent of job gains during recoveries. Based on history, what’s distinctive about this recovery is its sluggish pace, not the composition of its jobs. The economy’s growth rate has been less than half the rate of previous recoveries and the employment losses in the Great Recession were more than twice as large as those in previous recessions. The employment hole is much deeper, and it is taking much longer to get out of it.

Prolonged labor market slack has meant falling real wages for most workers. According to a recent study by the Economic Policy Institute, between 2007 and 2012 average real hourly wages for all private-sector workers grew by a paltry 1.2 percent. But this average obscures differences among workers at different skill and pay levels: real hourly wages fell for 70 percent of the wage distribution, with larger losses for those holding lower-wage jobs. During the year ended in mid-2013, real wages finally began to increase a bit for workers between the 50th and 70th percentile but continued to fall for those below.

In contrast, real wages have increased, albeit at a much slower clip than before the recession, for those in the top 30 percent of the wage distribution since 2011 and are up over the entire 2007-12 period.

Again, these patterns are not surprising. High unemployment harms wage growth across the wage distribution with the negative effect getting larger as one moves down the distribution. What is distinctive during this recovery relative to earlier ones is the growing disparity in wages across sectors, a trend that was apparent long before the Great Recession.

Between 2000 and 2007 real hourly wages increased 2.6 percent for the median worker, 1 percent for workers in the 20th percentile of the wage distribution and 4.6 percent for those in the 80th percentile. Over the entire 2000-12 period, real hourly wages were flat or declining for the bottom 60 percent of the wage distribution – and that’s despite productivity growth of nearly 25 percent during the same period.

According to economic logic, wage growth should reflect productivity growth. This was the case until the late 1970s. Since then, however, wage growth has fallen far short of productivity growth, and that’s true for workers regardless of education, occupation, gender or race.

The wage distribution has become considerably more unequal over the last 30 years, with top earners capturing a large share of overall productivity gains. The real median earnings of full-time workers aged 25-64 have stagnated after peaking in the late 1970s. There are many interrelated causes of wage stagnation and increasing wage inequality, including a drop in the real value of the minimum wage, disappearing unions and changing norms of fairness in pay. But technological change and the globalization it has enabled have played major roles, and these driving forces have probably strengthened during the recovery.

The Hamilton Project, from the Current Population Survey

Sample includes all full-time workers ages 25-64. Full-time workers are defined as those working 40 or more weeks. Earnings are adjusted for inflation using the CPI-U-RS.Jobs that are routine, that do not involve manual tasks and that do not need to be done near the customer are being replaced by computers and automation or are being outsourced to low-cost workers in other countries. Many of these jobs are middle-income and middle-skill jobs.

At the same time, technology is increasing the demand for workers who perform nonroutine tasks that complement automated processes or perform nonroutine, manual tasks that cannot be automated. Such tasks lie at opposite ends of the skill and wage distribution – from retail sales clerks and restaurant workers at the bottom to software programmers and engineers at the top.

The result is “polarization” of employment with job growth concentrated at the high and low ends of the wage and skill distribution and the disappearance of jobs in the middle.

These trends are apparent in most developed countries but are most pronounced in the United States. Recent data indicate that polarization has continued through the recovery: job growth has been stronger at the top and bottom ends of the wage distribution than in the middle.

The bifurcation of job opportunities has been a major contributor to growing wage inequality and that in turn has been a major contributor to the historic rise in income inequality that began in the 1970s. The deep recession and weak recovery have exacerbated these trends.

According to the recent Census report, the real income of the top 5 percent of households has recovered from recession losses and was about the same in 2012 as it was in 2007. In contrast, the incomes of the bottom 80 percent of families have not recovered to pre-recession levels. Median real household income in 2012 was still below its pre-recession level and about 9 percent below its all-time high in 1999.

According to another study, the top 1 percent of households captured 65 percent of real family income gains (including realized capital gains) between 2002 and 2007 and 95 percent of the gains between 2009 and 2012. In 2012, the top decile claimed more than 50 percent of income, the highest share ever.

The trends of disappearing middle-income jobs, stagnating wages and growing income inequality predated the Great Recession and are likely to persist even after the labor market has fully recovered, as measured by the quantity of jobs and the unemployment rate.

Without significant institutional and policy changes, supported by changes in social norms about wage inequality, the “new normal labor market” could feel a lot like the “old normal labor market” in terms of job quality for a large number of American workers.