Monday, March 29, 2010

Worth a Listen - Tony Judt on Fresh Air with Terry Gross

Tuesday, March 23, 2010

Maclen Muses – Explaining The Health Reform Bill

Explaining the Health Care Reform Bill By Mac Zilber

For those of you who know my mother, she has been advocating for universal health care since she moved to this country from Canada. She wanted me to write a guest blog for her to explain to her readers why, even though the health care reform that was passed yesterday is not quite universal, per se, it is a truly wonderful accomplishment for our country.

For those of you who know me, I am a policy wonk, so, rather than opinionate on the magnitude of this accomplishment, which, to be clear, I think is perhaps the greatest social achievement of our congress since Medicare, Medicaid, and Civil Rights, I am going to exercise my comparative advantage, which is to clarify to readers what exactly it is that this health care bill does.

The problems of the existing health care system that this bill sets out to remedy are the unparalleled costs of seeing a doctor in the United States (this is a good graph and the number of uninsured in the United States (about 50 million today, with another 20-30 million underinsured).

The uninsurance issue is dealt with by a tripod of regulating, mandating, and subsidizing insurance. Each leg of this tripod is necessary or the framework falls apart, as I will explain.

The regulations are numerous, and largely consist of piecemeal fixes to specific abuses by insurance companies. Insurance companies will no longer be able to take away your coverage if you get sick (While Carla has kept her coverage, nearly 50% of people who have medical expenses as high as hers lose their coverage), deny you coverage if you have a pre-existing condition, or charge you more because you’re a woman. There are a host of other regulations (the “doughnut hole” in Medicare is closed, youths like myself are allowed to stay on their parents’ health plan until they’re 26, and plenty more things that nibble around the edges), but these are the regulations that have received the most fanfare. The other important step towards ending the worst practices of insurance companies is reinsurance and risk-adjustment. Essentially, when an insured individual starts to cost large amounts of money to insurance company, there is a financial incentive for the insurance company to try to find a loophole by which they can drop that individual (though that will be much harder now). To remedy this, the government will set up a risk adjustment framework so that a sick person will be of the same expected value to an insurance company as a healthy person, thus removing that incentive. The final regulation I will discuss in this section is that there will be no more annual or lifetime caps on how much coverage you can receive, and out-of-pocket payments will be capped (at $5000 per year) as well. This is of incredible import to those of you in the ALS community whose out-of-pocket payments can extend above $100,000 per year. If this bill had been in effect when Carla got sick, she would likely have saved tens of thousands of dollars from the combination of all of these regulations.

Now, one of the most misunderstood parts of the plan is the individual mandate, which requires people to get health insurance, or, more aptly, creates a slight personal incentive towards getting health insurance. This has been mischaracterized as, alternately, a corporate buyout or a government takeover, but it is truly no such thing. Essentially, it says that, if you can afford health insurance (if the cheapest insurance plan available to you is less than 10% of your income), you need to buy it, or you will pay a penalty equal to 1% of your income. The reason for this is to prevent people from taking advantage of the new regulations by not signing up for insurance until they get sick.

Imagine a simplified insurance plan in which there are 5 people. One of them, say, Carla Zilber-Smith, costs the insurance company $50,000, and the other four cost the insurance company an average of $2,500, because they’re young and healthy, like, say, me. The insurance plan ends up costing $12,000 for each person (we’re removing administrative costs for this model), and, while it ain’t cheap, nobody goes bankrupt.

Now, imagine an alternate scenario in which I decide that, because I’m not currently sick, I won’t buy health insurance. Suddenly, the premiums of the remaining four people on the plan jump to about $15,000, and one of the other people can no longer afford the plan, and they leave the plan. The plan now costs $18,000 per person. Then I get sick, and my medical expenses are $50,000. Since the insurance company can’t deny me for pre-existing conditions, I re-join the plan, and the price per-person is now $26,000. At this point, the remaining two healthy people drop the plan, and the risk pool falls apart. This is known as the insurance death spiral. If you don’t allow insurance companies to deny for pre-existing conditions, you need to mandate “young invincibles” like me to buy insurance or the entire system goes into a death spiral, with only sick people buying health insurance.

Now, when you’re mandating people to buy a product, especially one as expensive as health care, you need to make it affordable, and that is where the subsidy part of the framework comes into play. For the first time ever, Medicaid will be available to any adult making under 133% of the poverty line (about $29,000 per year for a family of four), and, as a result, 17 million low-income individuals who are currently uninsured will be on Medicaid by 2016. People who aren’t poor but aren’t rich will receive a sliding scale of tax credits to make health care affordable for them, to the tune of about $80 billion dollars per year. This change will insure millions more people. This whole regulate-mandate-subsidize mechanism will ultimately reduce the number of uninsured Americans by around 32 million, meaning that, by 2016, 95% of Americans will be insured. It is also worth emphasizing that the bill requires that every insurance plan meet a certain standard of quality, so no only will 30 million people who would have been uninsured now have insurance, but tens of millions who are underinsured will now be more adequately insured. Finally, of the remaining 20 million or so who will be uninsured after this bill comes into effect, millions of them will be eligible for insurance, and will be able to enroll free of hassle if they become sick, and millions more are illegal immigrants. Indeed, if an immigration reform with a path to citizenship is passed, the number of people who aren’t either insured or operationally insured will drop to about 1-2% of the country.

To control costs, the health reform bill does a number of things, but there are three main ones: Bundling payments, an excise tax on high-dollar insurance plans, and the breaking up of insurance monopolies.

Bundling payments is arguably the most promising of the ways in which this bill controls costs. Currently, when you go to the doctor, your insurance company pays for each procedure individually, based on its marginal cost of the hospital. In economics, the cost of a service is typically the same as its marginal cost to the provider of the service, but, as Ken Arrow explained in his work on health and welfare economics, there is moral hazard and adverse selection at play when it comes to health payments. Say whaa? Essentially, what this means is that there is a financial incentive for a provider to give you insufficient treatment, or to over-treat you, because it means more treatments and more money. For instance, when I had a painful hot-spot on the bottom of my foot, it was misdiagnosed three times, I was given three prescriptions, three tests, sent to a specialist, and it turned out to be plain old athlete’s foot. I am not at all impugning the motives of the doctors involved, as they are great individuals, but the reality is that when you create an incentive scheme where such misdiagnoses are rewarded with more payment, you are going to have worse results. What this bill does is it creates a pilot program in which hospitals begin to be paid based on results, and what the cost should be, rather than the marginal cost is to them. In other words, a health care provider, if this is ultimately implemented systemwide, will know “I am going to receive X dollars to treat this specific symptom, therefore, I have nothing to gain by not doing it due diligence the first time around.” A provider of psychiatric health, who I will leave nameless, once told me that he sometimes feels the temptation to tell people that they aren’t cured, because his employer gets paid for each additional visit. By removing these incentives, this bill will allow doctors to have their good intentions and their financial incentives be aligned.

The excise tax on high-dollar insurance plans has been an oft-criticized part of the plan, and, much like the individual mandate, it is because it isn’t well understood. Essentially, every dollar over $27,500 that your employer spends on your health insurance plan is taxed at 40%. That means that, if your health insurance plan costs $28,000, the last $500 of it will be taxed, and you’ll pay a $200 tax on it.

The reason that this will control the growth of health care costs is that the current system, in which health insurance costs are exempted from taxation, creates a massive incentive towards overconsumption of health care, resulting in national per-person expenditures on health care that are over 70% above those of any other country in the world. How does this incentive work?

Imagine that Goldman Sachs has $500,000 to spend on a valuable and well-off employee. Each marginal dollar spent on her salary is taxed at 32%, whereas each marginal dollar spent on her health insurance plan is currently taxed at 0%. This means that, in a simplified model, without taking into account any of the nuances of the tax code, if this employee is given $490,000 in salary and $10,000 in health insurance, she’ll receive an after-tax salary value of $343,200. On the other hand, with the current incentive scheme in place, if she receives $450,000 in salary and $50,000 in health benefits, she will receive an after-tax salary value of $356,000. For any employee, health benefit spending will increase until it reaches an equilibrium in which the employee values $70 dollars of additional salary more than they value $100 of additional health benefits. This distortion in the incentive scheme is a huge reason that our health care costs rise at 7% per year.

Now, here is how the excise tax helps fight that. Going back to the example of the high-paid executive for Goldman Sachs, in the first year of the excise tax going into effect, her incentives, and the company’s incentives, point towards her health benefits dropping to $27,500, and her salary increasing to $472,500 to pick up the slack. Over time, this tax begins to affect more and more people, and, thus, squeezes more and more overconsumption out of the system.

The final way in which this bill will reduce costs is to create a competitive market for insurance. Currently, the vast majority health insurance markets would be considered to be in violation of anti-trust laws if the insurance industry didn’t have an anti-trust exemption. This will change that. Essentially, when you’re purchasing insurance, you will be able to go onto a website similar to (product placement, yay) in which all insurance plans in your state are compared side-to-side, with reviews, ratings, benefits, etc. Imagine if you called every car dealer within a 50 mile radius and said “I am going to buy a car, and I am calling every car dealer in a 50 mile radius. Whoever makes me the best offer will make the sale.” It would be pretty hard for a car salesman to gouge you on the price, huh? Similarly, by listing all plans next to each other in a competitive market with community rating, insurance companies won’t be able to jack up prices or reduce benefits without you, the customer, being able to switch plans. By 2019, 8 million people will have switched from their current plan to purchasing health insurance on the exchanges, and an additional 16 million people who were uninsured will have purchased health insurance on the exchange. By giving the consumer power, costs will be controlled, and insurance companies will have to compete in the good old fashioned way; by offering a better deal than their competitors.

The last question people typically ask is how we are going to pay for this. The costs per year, once the plan is in place, will be about $160 billion per year, or about 1% of our economy. The tax on Cadillac plans, a small payroll surtax on the wealthy, and certain fees to be payed by insurance companies, drug companies, and hospitals, will yield about $70 billion per year (though this number will increase substantially after about 10 years). Targeted cuts in Medicare waste and fraud, as well as some of the aforementioned cost controls, should save about $100 billion per year, though this number will also increase over time. Over the first ten years, this bill will yield a surplus of about $138 billion dollars (a relatively small amount, over ten years, but a surplus nonetheless). Over 20 years, this bill will reduce deficits by over one trillion dollars, though many economists believe the number will likely be even larger than this. This bill on its own will not prevent a sovereign debt crisis, barring further action, but it will be the most fiscally responsible bill that congress has passed since the Clinton budget of 1993.

At the end of the day, though hundreds of billions of dollars, tens of millions of insured people, and tens of thousands of saved lives will all be nice perks, I think that Carla has the best sales pitch for what may prove to be the crowning social achievement of our generation: “For the first time in our country’s history, if you’re sick, no matter who you are, you can see a fucking doctor.”

Mac Zilber is Carla Zilber-Smith's son. He is studying American Politics and Comparative Politics at the University of California at San Diego, and is the Director of Policy for the UCSD Student Government. He is a huge nerd. The kind who you would probably push into a locker if he wasn't six feet tall, funny, and good-looking. And yes, he wrote this blurb, and is just talking about himself in the third person. Feel free to ask him any further questions, as he is willing to talk ad nauseum about policy, and he figures he probably has at least one unclear sentence, given that this blog is ten pages long and wasn't really edited.

Sunday, March 21, 2010


A Night of Gratitude - A Special Evening With Carla Zilbersmith

Tuesday, March 23, 2010
Time:6:30pm - 8:30pm
Novato Seventh-day Adventist Church
495 San Marin Drive
Novato, CA

Carla (the star of Leave Them Laughing, directed by John Zaritsky) will be giving an extremely rare lecture about her life and how she learned to appreciate the beauty of every moment despite being diagnosed with a fatal illness, ALS (Lou Gehrig's Disease). Carla has truly learned how to embrace every succulent moment and she'll show you why you should too.

Come for inspiration. Leave changed.

To reserve tickets or for more info,
or call 415-497-2313
$15 donation requested

For more than fifteen years, Carla Zilbersmith wrote and presented an amazing array of musical and theatrical scores, scripts, one-woman plays, and songs. Carla and her band the SubUrbans were Lilith Fair finalists, she was the founding member of We’re Redheads, a women’s sketch comedy troupe, and Lighten Up John, a musical improv group, as well as serving as the Artistic Director of the College of Marin Drama Department before ALS rendered her unable to perform, sing, or teach.

Monday, March 15, 2010

What This Night Is Like

It’s somehow coming to the conclusion that the only way to make this night tolerable is write a blog (maybe the first ever) while on the toilet unable to shit.

It’s waking up in the morning and checking Facebook to see that you’ve lost another friend. Nobody unfriended you or defriended you. They just had ALS and they died.

It’s one minute caring a lot about a hair style or the latest crazy idea turned into a big project and wishing the next minute that you could just die already.

It’s feeling a fist sized shit rip your asshole open and not being able to bear down or catch a breath. It’s that you have this feeling not once but twice in one day even though you cut out morphine and had a prune smoothie.

It’s 21 drugs and counting and wondering when you will be dubbed the fucking Baskin Robbins of pill poppers.

It’s realizing that expecting a clear sign that it’s time to die is like driving down a pitch black remote country road and expecting to hear “All Things Considered” or “Wait, Wait, Don’t Tell Me,” instead of hours of white noise and static mixed with snippets of some crazy fundamentalist ranting about the gays and the Jews.

It’s paying a heavy price for every fun day.

It’s wondering why the others like Megan or Scott seem to handle so much more crap than you do and wondering if you are a wimp or if you’ve just had enough.

It’s running out of words but still not passing this fucking ball of shit.

It’s realizing that life is a no good rotten man who beats on you and cheats on you and looks just like Jon Hamm as he stares in your eyes and whispers softly “come on baby, you know we are meant for each other.” And instead of wanting to quit him, you wanna hang in there for one more great shag. Fuck you Jon Hamm.

It’s knowing that someone is going to commiserate with you by saying, “Girl, I know what you mean. I was constipated once” and you are going to have to bite your tongue and not say, “Unless you have ALS, you do NOT know how I feel unless you’ve rubbed a cheese grater across your asshole for a good 10 minutes at least.”

It’s exhausting.

Fundraiser Posted by my friend, Gina

A Night Of Gratitude

A Special Evening With

Carla Zilbersmith

Tuesday, March 23rd
Novato Seventh-day Adventist Church
495 San Marin Dr., Novato

Carla will be giving an extremely rare lecture about her life and how she learned to appreciate the beauty of every moment despite being diagnosed with a fatal illness, ALS (Lou Gehrig's Disease). Carla has truly learned how to embrace every succulent moment and she'll show you why you should too.

Come for inspiration. Leave changed.

To reserve tickets or for more info,
or call 415-497-2313
$15 donation requested

For more than fifteen years, Carla Zilbersmith wrote and presented an amazing array of musical and theatrical scores, scripts, one-woman plays, and songs. Carla and her band the SubUrbans were Lilith Fair finalists, she was the founding member of We’re Redheads, a women’s sketch comedy troupe, and Lighten Up John, a musical improv group, as well as serving as the Artistic Director of the College of Marin Drama Department before ALS rendered her unable to perform, sing, or teach.

Saturday, March 13, 2010

Happy Birthday Kaila

In the late 1990's, I was driving to work and listening to the radio when a haunting and compelling artist was introduced to me. Her music affected me so much that I pulled off the highway to write down her name. After work I drove straight to Down Home Records and bought Kaila Flexer-Third Ear. Little did I know that ten years later this amazing composer and violinist would be one of my best friends and one of a small handful of people who would dedicate time every week without fail to the grunt work of helping me out. I don't know anyone with more responsibilities than Kaila and yet she has made it a priority to be there for me for all the tough stuff - overnights with coughing and suctioning machines malfunctioning, getting me ready to go onstage while I howl and sob like a wounded animal, ruining my make-up in the process and taking me out for dinner and having to feed us both.

Kaila balances her performing career and her teaching career with raising the most remarkable ten year old daughter, Lucy. Kaila 's ex is a touring musician so while she is not really a single mom, her life often looks like she is one. How she manages to find time each week for me is anybody's guess

Kaila has written not one but three beautiful pieces of music for me. One of them is posted after this blog and if you like what you hear, go to www. There are so many legitimate reasons people have for not carving out time in a busy life to help a sick friend and Kaila could use almost all of them but instead she chooses the tougher road. But this is not why I love her. I love her passion and her indefatigable romantic spirit. I love her irritating perfectionism and her unwavering artist integrity. I am stirred by her moral outrage and wickedly amused by her lady like sensibilities that I disturb on a regular basis. Kaila is an amazing mother and the fierceness of her love has paid off. Her daughter is a strong, independent, creative and hilarious kid whose visits beam a floodlight of joy onto my day. But Kaila is not just mother to Lucy, she is maternal to friends in need too. She is the kind of friend who will drive you to the airport, fix you the perfect snack or move heaven and earth to help you in your performing career. She is also unusually beautiful. When Kaila plays music this fiery passion consumes her so even straight women thinks she 's hot.

I like to tease Kaila about how easily she cries (we're talkin' so so easy) but truth be told I envy her overflow of compassion I am moved by the way she feels so deeply on someone else's behalf.

So here's to my beautiful crazy brilliant loving friend. Happy Birthday Special K! I love you. .

Teslim - Stone's Throw (for Carla)

Wednesday, March 03, 2010

News Flash: There are literally thousands of religions

I received what I believe was a very well intentioned blog comment the other day. I have had many of these kinds of comments and the blog below is one that has been a work in progress, which I come back to every time someone expresses concern for my immortal soul. I’ve never had the guts to actually post it lest someone take it the wrong way, but here goes:

The lady who wrote me this time hoped that when my suffering ends, I would be able to rejoice for eternity in a new and perfect body if I simply confessed my sins, believed on (sic) the name of Jesus as the son of God, and asked Him to save me.

First of all, my caregiver Alexa wanted to know if my new perfect body would have red hair and great tits because otherwise it would be a downgrade. Second of all, some of my best friends love Jesus and third I want to say to anyone who follows any faith that I’m happy you have a source of comfort in your spiritual beliefs. I can only surmise that these beliefs are very deep and profound for you and have helped you tackle the challenges in your life. You found something valuable and I understand the desire to share it but give me a little credit, will you?

That being said, I am not a Christian. I am a very spiritual person and it is for that reason that I have difficulty aligning myself with any given faith. When my brother and I were young, he believed that God invented all major religions so that people with different ways of worshipping could all feel a part of something. It was a charming and hopeful theory, one that put the brightest face on the way in which humanity has used God, faith and religious beliefs to commit unthinkable crimes. Sadly, I must say that ever since the Middle Ages the Christians have been the top contender for the gold medal of the Atrocity Olympics.

But what does that have to do with Jesus, you might ask? Very good question. After all, should he be held accountable for all of the cruelty and evil that have been done in his name? If we look at Bible II – The Return of the Son, do we not find in all of his teachings the keys to compassion, to equality, to social and economic justice?

Hell yeah.

Muslims believe Jesus was a prophet. Some Jews call him Rabbi. Historians versed in Aramaic would use literal translations of the text recounting Jesus’ last days to prove he was a revolutionary—a Che in sandals. Did you know that the Aramaic word that we have translated as garden (as in Garden of Gethsemane) is more literally translated as fortress? Many scholars believe Jesus and the Apostles did not surrender peacefully to the Romans after a kiss on the cheek but rather, fought to hold off their foes behind the formidable walls of Gesthemane.

Did you know that the Gospels of Matthew, Mark and John are wildly different in their accounts of Jesus’ last days? It’s my guess that Jesus was probably a composite character of a number of amazing men: rabbis, prophets and revolutionaries. All of these men, no doubt touched the lives of the people with whom they came in contact. None of them, I would imagine, turned loaves into fishes, walked on water or rose from the dead; but when we encounter someone so much larger than ourselves, someone who is capable of expressing so much more than we can, why not say, “He came back to life.” Or “He turned water into wine. Because the miracle of encountering such a person is so over-whelming that only metaphor can do the experience justice.

That’s why for me, God is in the first movement of Beethoven’s Third Symphony. God is the soft touch of lips on skin. And God is in people, like someone (let’s just call him… Jesus) who leave the world better than it was when they arrived.

I don’t want to convince anybody that their religious faith is not real or valid. I’m just letting you know that sometimes you need to find out to whom you’re talking to before you tell her that Jesus is the only answer. You may be talking to someone with deep roots in another religion. You may be talking to someone who is dying and who resents being told how to do something that you yourself will not (I hope) be experiencing for sometime. You may be talking to someone who has studied biblical history or who has read so much of the Sufi poets’ devotional works to God that she can recite dozens off by heart. You may be talking to someone who spends a considerable chunk of every day thinking about theological/spiritual issues and doesn’t need or want your guidance in such an intimate choice. Make up your mind: are you a devout follower of an ancient religion or are you a glorified Amway salesman? If you are the former, you will accept me for who I am. If not, I don’t want any.

I love my notion of Jesus. I love to imagine a modern-day Jesus preaching gay marriage, universal health care, love, sex, beauty, art, passion, socialism and whatever else came to his head. But the thing I love most about this guy, the one in my imagination, is that he’s not going to die if I don’t believe in him because HE’S JESUS NOT FRICKING TINKERBELL. Plus he’s already dead.

Maybe twice.

Maybe not, who knows.

Jesus believes in me just as much as I believe in him because to do otherwise would rob his followers of personal responsibility and independent thought. Finally, this modern-day Jesus would not attract some of the people that worship the old Jesus (like Pat Robertson, lots o’ Republicans and any other douche bags who go around hate-mongering in his name) but he would attract generous, talented, hard-working people…like you Christian people I love and respect.

I close with a friend of mine who expresses these ideas better than I can. Plus the blog post directly below this one is from another friend, Roy Zimmerman, who has his own interpretation of this argument.

Jesus Incognito
By Alison Luterman
(from The Largest Possible Life)

Don’t tell anyone, but I love Jesus.
I love his big dark Jewish eyes, so full of suffering soul,
like an unemployed poet’s, and his thick sensuous Jewish lips,
and his kinky curly hair, just like mine, uncontrollable despite conditioners,
and the way he always argues with everyone
and will go to hell for love.
He’s just like that Buddhist god Avalokiteshvara, the bodhisattva of compassion,
except his name is easier to pronounce.
When you’re in trouble it’s hard to remember to yell for Avalokiteshvara,
but “Oh Jesus!” arises naturally
every time a crazy driver hot-dogs past me on the freeway.
I know I should say the Shema when I’m about to die,
but will I be able to remember Hebrew at a time like that?
I don’t want to die saying “Oh shit!”
I’d like to leave my body consciously, like a Tibetan lama, sitting in full lotus
with my head turned toward where I’ll reincarnate next.
But let’s be realistic: I probably couldn’t meditate enough to become enlightened
in the however-many years I have left.
Jesus seems easier. All you have to do is love everyone.
Well, seems is the key word here.
Sometimes the more you try
to love people, the more you hate them.
Maybe it would be better to try
not to love people, and then watch the love
force its way out of you like grass through cement.
Anything is better than organized religion.
I don’t like the singing in churches — all those hymns in major keys.
I don’t think religion should sound so triumphant.
It should be humble and aware of the basic incurable pathos of the human condition,
and in a minor key and sung in a mysterious ancient language, like Sanskrit or Hebrew.
Is it OK for me to love Jesus but not be Christian?
I could try to open my heart and give away all my possessions.
It’s not that different from being Buddhist, after all, except for a history
of witch burnings, the Inquisition, the subjugation,
rape, and pillage of indigenous peoples all over the world,
not to mention twenty centuries of vicious anti-Semitism. That’s a lot to overlook
to get back to a baby born among animals to a Jewish mother, Miryam.
And what about that other Mary, the sexy one? Jesus, I don’t believe you died a virgin.
I think you needed to taste everything human, to inhabit the whole mess:
blood, shit, flies, regret, envy, why-me.
I owe you and all the other bodhisattvas and sages
and newborn babies a debt of thanks
for agreeing to come back and marry yourselves
to our painful predicament again and again —
and I do thank you, bowing to the infinite directions.