Priceless? Really?

By: Laura Mortimer

Our Thanksgiving transportation choices were clear. Option One: Drive 12 hours from Durham, North Carolina to Jackson, Mississippi, pay about $200 in gas round-trip, bring the dog (I adore the dog). Option Two: Fly 6 hours from Durham to Jackson (no direct flights), pay about $1200 for two round-trip tickets, board the dog for $300.

To recap:

Option One – $200, 12 hours, four-legged princess

Option Two – $1500, 6 hours, no princess

Economists refer to non-monetary costs (time, dog’s company, etc) as opportunity costs. Of course, other opportunity costs factored into our choice – road traffic, flight delays, gross gas station coffee, gross airplane coffee – but, as income-less graduate students with limited financial resources, we knew that money was our main constraint.

Feeling sorry for us, and generous, my mother offered to pay for one of our flights. That would have knocked our Thanksgiving bill down to $900 – a real steal for Aunt Ethlyn’s sweet potato casserole.

…really?

We thanked mom for the offer but assured her that we would much rather drive than spend an additional $1300 (of anyone’s money) to shave a few hours off our trip.

Enter that which mom considers priceless: church. If we’d flown, we could have left Sunday afternoon instead of Sunday morning. My mother was willing to pay $600 (probably more) for us to sit in the pew, and she expected us to do the same. She contends that this kind of family time – like Aunt Ethlyn’s casserole – is priceless.

I once paid $20 for a fancy bar of soap (in New Orleans, possibly after a few drinks). I am no Spock. I don’t think anyone would consider me a “heartless economist.” But I do think rationally enough to have trouble considering any thing truly priceless.

At the very least, I think about tradeoffs when resources are limited. Flying home at Thanksgiving might mean not making it back for Christmas. So it goes.

Here’s where it gets weird. When decisions are highly emotional (family holidays, wedding planning, etc), many people have an uncanny ability to ignore the limitedness of their resources. I must have felt very strongly about that lavender-scented soap in NOLA, because my graduate student budget does not allow me to buy designer soap.

I often wonder if this is a particularly American conundrum: expecting to have our cake and eat it too. American healthcare is perhaps the most striking example of this weird complex.

In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals to provide emergency treatment to anyone who needs it, regardless of their ability to pay. Hospitals may not get reimbursed for treating these patients – hence, uncompensated care. No healthcare provider likes uncompensated care.

And yet, this same system refuses to provide insurance coverage for every American – insurance that would alleviate hospitals of the burden of uncompensated care. States that do not expand Medicaid have a gaping hole in health insurance coverage: people who earn between zero and one hundred percent of the federal poverty level in those states do not receive Medicaid or financial assistance to buy insurance on the exchange. When these people have heart attacks or car accidents, they will still receive emergency room treatment, thanks to EMTALA.

Hospitals will lose money because no one pays for these visits. Some hospitals will close their doors because these costs put them out of business. But Americans can sleep alright – for tonight, at least – knowing that we didn’t have to say no today.

We can do better than this. Look at the federal budget – or any state or hospital’s budget – and you’ll see that we have to do better. We must find ways to provide healthcare more efficiently. This means covering more people at lower costs, and finding ways to balance our emotions around healthcare and our pocketbooks. It means thinking creatively, intelligently, and objectively about how we provide care. It probably means big changes.

I am encouraging a mid-October family reunion next year, in lieu of hectic and costly Thanksgiving travel. Who says you can’t serve sweet potato casserole and pecan pie on Columbus Day? Maybe the family will go for it, maybe not. I just hope we can find ways to maintain that which really is priceless – our relationships – without placing irrational demands on one another.

Mind the Gap in Healthcare

By: Laura Mortimer

What is good healthcare? Is patient-centeredness possible?

Despite working in the same healthcare “system,” leaders in business, medicine, and public policy often answer these questions differently.

 I spent Saturday at a healthcare conference titled “The Evolving Healthcare Landscape: Mind the Gap Between the Patient and the Healthcare System” at the Fuqua School of Business. The conference was excellent, though I’m still a little unclear on what it means to “mind the gap.”

A more progressive approach might have been to fill the gap, or at least explore it further and understand it better. Why are patients disconnected from the system in so many ways? Why is this chasm dangerous? What does it cost us?

Also, why did the conference organizers not make more British puns about the London tube?! Lost opportunity.

A good starting point for answering these questions would be to examine various perspectives of major players in the U.S. healthcare system – leaders in medicine, business, and public policy. Success from a physician’s perspective may look very different than success from a pharmaceutical executive’s perspective, and so on.

Not to mention the patient’s perspective, which remained noticeably absent from much of Saturday’s conference.

That may have happened because patients are not the power players in our healthcare system. Patients stand at the receiving end of long chains of negotiations, market forces, and scientific developments. Consequently, the popular move toward a more “patient-centered” system is much easier said than done.

The conference’s keynote speaker from GlaxoSmithKline – the world’s fourth largest pharmaceutical company – discussed his company’s efforts to bring its customers’ voices into the research and development process for drugs. However, GlaxoSmithKline’s customers are large hospital systems, not patients.

The keynote speaker talked about the need for greater patient adherence to medications. I couldn’t help but wonder, has this man ever considered that some patients may not adhere to their meds because they can’t afford regular refills? Or because what he assumes is a simple trip to the pharmacy requires two buses and a babysitter? Or any of the other circumstances that a truly patient-centered system would consider?

The gap between patients and system is large. And, despite all the rhetoric, it doesn’t seem to be getting any smaller. Who will change this? Who has incentives and power to change it?

Publicly traded companies like Glaxo must honor their fiduciary responsibility to their shareholders, so their greatest incentive is to maximize profit. Physicians are responsible to the oath they take to do no harm and provide the best possible care for every individual. And policymakers are responsible for the whole – for maintaining civic environments that are ripe for both businesses and individuals to flourish. Again, easier said than done, especially when goals within the healthcare system often conflict.

Public policy may be the best tool we have to promote societal health and make “the gap” less costly. Policy can help align the goals of different players in the healthcare system and give patients more agency. The Affordable Care Act moves us forward a few steps, but we still have a long way to go before honestly saying that our system provides good, patient-centered care for every American.

Financial Literacy Matters

By Aziz Gulhan

British Prime Minister William Gladstone articulated the importance of finance in his famous quotes in 1858: “Finance is, as it were, the stomach of the country, from which all the other organs take their tone.” A well-functioning financial system is considered a prerequisite of sustained economic development. It is clear that the recent financial crisis has changed the fundamental streamline of the world’s financial system. Financial architecture has been evolving since the Lehman Brothers, one of the world`s largest investment banks, went bankrupt in September 2008.

Some suggest that the lack of financial literacy of households is one of the key factors that led to the swelling of the mortgage crisis in the U.S. Since most people were not aware of the potential risk of what changes in interest rates would mean for credit, they did not hedge their financial position against the unexpected outcomes that could occur in financial markets.

United States Government Accountability Office (GAO) defines the financial literacy as an ability of making informed judgments and taking effective actions in regarding money. The Organization for Co-operation and Development published a detailed working paper in 2012 (OECD Working Papers on Finance, Insurance and Private Pensions, No. 15) regarding the current situation of financial literacy in selected countries. This working paper presents a pilot study undertaken in 14 countries (Armenia, Czech Republic, Estonia, Germany, Hungary, Ireland, Malaysia, Norway, Peru, Poland, South Africa, the UK, Albania and the British Virgin Islands).

According to the survey results, understanding daily financial terms such as compound interest and diversification of risk are lacking for significant shares of the population in all 14 countries. The study also points out that men have more financial knowledge than women in most countries, which is a noteworthy concern that countries should address. Another considerable result from the study is that knowledgeable people are more likely to show positive financial behavior. This study goes further to claim that low levels of schooling and income are also associated with lower levels of financial literacy.

The concept of financial literacy is becoming one of the core issues in finance, especially for middle-income households. Since financial instruments are getting more complicated and there are more opportunities to make investments, individuals should be well-equipped to analyze the risk of financial decisions.

According to Annamaria Lusardi, the Director of Global Financial Literacy Excellence Center at George Washington University, individuals have to make more decisions on their savings and investments than in the past. Therefore, specific needs and the economic capability of individuals should be recognized when making financial investments.

Governmental and non-governmental organizations have established some programs to improve the level of financial literacy. For instance, Securities and Exchange Commission (SEC) provides a website (www.investor.gov) to promote investment and inform the individuals about their financial decision. National Association of Investors Corporation (NAIC), also known as BetterInvesting, is a Michigan-based non-profit organization which has 120,000 individual members, proposes to teach individuals to how to become successful decision-makers regarding financial instruments. Khan Academy (www.khanacademy.org) also introduces free online courses for the fundamentals of capital markets and finance.

Policies towards improving financial literacy need more collaboration among regulatory institutions and non-profit organizations, as well as, international considerations. At this point, policy makers should design effective training programs focusing on individual needs of potential and current investors.

Obama’s False Promise

By: Laura Mortimer

President Obama repeatedly promised Americans over the past four years that, “If you like your healthcare plan, you can keep it” under the Affordable Care Act . Yet, insurance companies are terminating millions of Americans’ plans because those plans do not meet ACA standards.

The President even apologized – a rare move for any POTUS – on Thursday to Americans who lose their plans, although it was only sort of an apology.

Why does this bizarre discrepancy exist between what President Obama said would happen and what is actually happening with health coverage? Sarah Kliff at the Washington Post does a great job of answering this question here. If you make it through her entire post, I’ll buy you a beer at Sam’s later.

My big question is: Why did the President use this promise as a rallying cry for the ACA if he and his administration knew all along that it wasn’t true for millions of Americans?

The (unfortunately frequent) answer: Politics. They needed the votes.

The more nuanced answer, however, is that most people do not like change. By reassuring Americans that their healthcare plans would not change under his health reform, President Obama hoped to assuage people’s fears that healthcare Armageddon would ensue.

Meanwhile, by scaring people with death panel talk and nightmares of Uncle Sam in the exam room, Republicans did their best to make Armageddon a reality in people’s minds.

The administration issued its wholesale messaging about not losing coverage under Obamacare largely in response to these scare tactics. Both sides severely distorted the truth, however, leaving Americans afraid and confused about what health reform really means.

American Jewry: Desperate Times

by Michael Landes

“A house divided against itself cannot stand.” How ironic that American Jewry must hear this advice from a different religion. Jews in America are divided – and while we stand apart, we cannot retain our character as a Jewish people.

Jews of all stripes are up in arms in the wake of the now-infamous Pew survey of American Jewry. Much has been made of our apparent decline in faith-based identity, the rising tide of intermarriage, and the frightening conclusion drawn by Pew researchers that Jerry Seinfeld may be more important to most Jews than G-d.

So far, nearly every response to the pervasive fear of Judaism’s demise has been something I’ve heard before: blame. The Conservative movement has no true definition, so its constituents leave. Reform Jews have no identity. Orthodoxy is too rigid and isolationist. Name your group and they’ve contributed to our downfall.

Enough pointing fingers. Enough hand-wringing. Judaism is indeed in crisis in America. So what are we going to do about it?

If we want to rebuild our community, sustain our faith, support our institutions, then we need a cross-denominational moment of introspection. When was the last time we saw denominations interact with one another outside of a college campus? How many Reform Jews can describe what it really means to be Orthodox? How many Orthodox Jews know how the Conservative Movement makes its legal decisions, and how many Conservative Jews can explain Reform theology? These movements rarely care to teach their constituents about other traditions – and when they do, it is most often at the expense of the other.

Would it really be so radical to try learning about one another?

Lay leaders: introduce joint conventions between youth movements. If one denomination does something differently from another, then let the youth themselves explain what they do and why. Give kids an opportunity to understand one another on a relatable level.

Require Jewish education to include speakers and representatives from different movements. Allow them to speak in our classrooms. Introduce joint Tikkun Olam projects – every movement emphasizes social justice, and they can teach one another about their motivations and practices.

Perhaps most importantly, sit together. Eat together, and do so during holidays and celebrations. Talk, and nurture empathy and understanding. The answer to our people’s future is in the ability to recognize value in diversity of opinion, even when those opinions run contrary to one another.

What does this idea demand of us? It requires that we accept one another for who we choose to be in the context of our faith. It forces us to recognize that by exposing our children to other aspects of our modern culture, their lives are apt to change in the direction of their choosing. Yes, some Reform children may become Orthodox, some Reconstructionist children may become Conservative. But the point is not the outcome of their decision – rather, it is the act of choosing that impresses identity upon the next generation.

It will be painful, and it will be difficult to accept. But if we’re serious about saving our future, then it’s time we thought about the nature of Jewish identity in a new light: where denominations should be boundaries only in the sense of self-definition, and never in a social context. It is time for our institutions to stop separating us.

Michael Landes is a graduate of the List College Joint Program between the Jewish Theological Seminary and Columbia University. He is currently studying for his Master’s in Public Policy from the Sanford School at Duke University. He is expected to complete his studies in May of 2014.

Who is responsible for the health of this child?

Aixa Cano was described in a recent AP article as a shy, 5-year old girl from Chaco, a poor farming province in northern Argentina. What makes her different than most 5-year old girls is that Aixa was born with hairy moles all over her body. She fared better than her neighbor, Camila, a 2-year old girl born with multiple organ problems. Doctors, who cannot explain Aixa’s condition, say her birth defect may be linked to agrochemicals. The Argentine national government must hold itself responsible to protect the health of children born in rural areas.

Agrochemical use in Argentina has increased greatly according to the AP report, increasing from 9 million gallons in 1990 to 84 million gallons today. While it has led to a huge growth in agricultural production, rates of cancer and birth defects have increased dramatically in Argentina’s rural farming communities. In Aixa’s home province of Chaco, regional birth reports given by the AP show congenital birth defects soaring from 19.1 to 85.3 cases per 10,000 people in the decade after genetically modified seeds and their partner agrochemicals were approved in Argentina.

So if we were to assume an excessive use of agrochemicals leads to birth defects in children like Aixa, who is responsible for their misuse? Farmers and agrochemical companies, whether we like it or not, work to make money and not improve public health. If farmers don’t spray enough chemicals and their crop decreases, they lose money. Regarding the local government, while they should be out to protect public health, this mission can often be lost in the cause of economic development, which in rural communities often comes from agriculture. Thus, in my opinion the Argentine national government is at fault. The national government, while still influenced by the agriculture industry, is more able to resolve the problem than rural provincial governments because it is more isolated from agriculture’s impact considering the diversity of the national economy.

To remedy the problem, there are three things that I believe the Argentine national government can do better. First, it should change agrochemical regulation standards from being made at a provincial level to a national level. This will create clearer standards, and avoid undue influence by industry in poor provinces that depend highly on agriculture. Second, the national government should complete the work of the presidential commission formed in 2009 to study agrochemicals and health. They can do this by properly funding programs to fortify local government monitoring of agrochemical application, along with programs to educate farming communities on proper agrochemical use and application. Finally, the government should listen to its constituents and fund studies to investigate the potential health effects of agrochemical use.


The Elusive Cost of Care

My right knee started bothering me on a long run a month ago. After weeks of pain, fruitless physical therapy, and no clear diagnosis, I had an MRI scan of my knee. Thankfully, nothing major showed up – just a persistent case of tendonitis. As a competitive runner hoping to compete in the Olympic Trials, I asked my doctor several questions: When will I be able to run again? What kind of cross-training should I do in the meantime? How many times a day should I ice? What can I do to keep this tendonitis from recurring? Should I hold off on buying plane tickets to that big race in December?

I failed to ask one important question, though: How much money will I have to pay for treatment? This failure is especially frustrating and surprising since my year-long Master’s Project focuses on clinical conversations about healthcare costs. I spend hours each week reading, writing, thinking, and talking about how doctors and patients can more effectively discuss out-of-pocket costs. If anybody should have the knowledge and resources to discuss medical costs, I should.

Yet here I was, a patient so focused on my running career that I completely forgot to ask how much my knee injury would cost. That MRI had a price tag worth more than just time, but my doctor and I did not discuss my ability or willingness to pay for it. Later, I felt stupid for agreeing to an expensive test without first knowing the toll it would take on my bank account.

I justified my experience somewhat by knowing the high value I placed on the information an MRI could offer. Even if I had known the exact stomach-churning price of my MRI, I probably still would have gotten the test. Others in my position may not have placed as high a premium on that information, however, and would have chosen a few more weeks of watchful waiting over high-priced MRI test results. The absence of cost information makes it nearly impossible for most patients to decide whether such tests are worth it for them.

Once I returned for my follow-up visit, I investigated the cost of my MRI in earnest. I spoke with half a dozen Duke Sports Medicine employees to try and learn how much I would pay for this test. None of these people could give me an answer. I have the same insurance as most Duke students – Blue Cross Blue Shield Student Blue – so I pay 20% coinsurance for most treatments, tests, and procedures. This means that, to learn the amount I pay for an MRI, I must first know the total cost of the MRI (then I pay 20% of what’s left after I pay the co-pay). No one at the clinic could tell me the total cost – not even the patient financial counselor. I had no possible way of knowing my out-of-pocket cost.

Patients have experiences like mine all the time. Most patients, however, do not study health policy and are even less well equipped to find, discuss, and consider healthcare costs. This is a huge problem. Duke Professor Peter Ubel argues that healthcare providers should make patients aware of the “financial toxicity” of treatment options, just as they discuss other potentially toxic side effects. Rule Number One of functional, competitive markets is that consumers – patients, in this case – should have access to the information necessary to make rational economic decisions. To the extent that healthcare is a market in this country and patients pay for their care with “skin in the game,” their ability to make good decisions is severely limited by the absence of treatment cost information.

Both healthcare providers and patients have a responsibility to consider patients’ out of pocket costs when making treatment decisions. Policy can enable these discussions by making cost information more accessible. Price transparency laws, cost calculators, and clinical communication aids are just a few of the alternatives that policymakers and healthcare administrators are currently exploring.

But policy alone cannot drive this major change in clinical culture. Insurance companies and other stakeholders must also shift to more patient-centered perspectives to foster good communication and create truly competitive healthcare markets. This means designing user-friendly insurance policies with less fine print, making all out-of-pocket costs available for patients and their doctors to discuss when deciding on treatments, and creating a healthcare culture that encourages and rewards effective communication around cost issues.

Until these changes occur, the onus will remain on patients to include cost queries in their litany of questions for medical providers. But even then, clinicians may not have the resources to provide answers.

Did you know there’s an election Tuesday?

Many of us might be unaware of Tuesday’s election. The voter turnout for last month’s primary was only six percent.

“How could this institution of local representative democracy have escaped my attention?” you probably said out loud.

Worry not; you can reestablish your standing in the Civic Engagement Club. Take five minutes and read below. You’ll have a more informed opinion and democracy will work like intended. Then on Tuesday, vote vote vote!

But only vote once. That was just for inspiration.

This Tuesday, November 5th, Durham will elect a Mayor and three city council members. The deadline to register to vote was October 11th. Everyone in the city can vote for all the city council candidates, but candidates must reside within the ward in which they run. Check out this map to determine your ward.

Read an overview of the election and candidates, or let this voter guide help you.

Mayoral Candidates

William “Bill” Bell, a Democrat, is the current mayor and has been since 2001. He will face challenger Sylvester Williams, an Independent, for the second time in two elections. Last election Bell won with 82 percent of the vote to Williams’ 18 percent.

You can find full answers to candidate questions here for Bell and Williams (Williams’ responses are from the election two years ago). Briefly:

Williams is currently a pastor at The Assembly at Durham Christian Center and worked as an investment analyst for 25 years. He would like to use public funds to create jobs in Durham, and increase salaries for police officers and hire more. He opposed past city council rulings to allow Mexican migrants to use Mexican issued IDs, and support same-sex marriage.  

Bell is a former Durham County Commissioner. He is a Democrat and describes himself as socially progressive and fiscally conservative. He wants to reduce crime, and increase affordable housing and neighborhood revitalization. As a commissioner Bell supported the merge between the city and Durham County Public Schools, and also supports domestic partnership rights for city employees. He recently butted heads with the city council over utility extensions to the 751 South development.

City Council Candidates

Ward 2: Howard Clement is vacating this council seat after 30 years of service. Eddie Davis is running against Omar Beasley.

Ward 3: Pam Karriker is running against incumbent Don Moffit.

Ward 1: Cora Cole-Mcfadden is running un-opposed.