Fancy dorms

High-rise and upscale LightView apartment complex, for college students in Boston

High-rise and upscale LightView apartment complex, for college students in Boston

From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

In New England and elsewhere an increasing number of colleges and universities are collaborating with private developers to build fancy apartment buildings (or call them “dorms’’) with heftier rents than students would pay to live in the usual barebones (often cinderblock) dorms.

In one way you could see this as a good thing because companies, not the colleges, pay to build the somewhat luxurious “dorms,’’ saving the institutions a lot of money (especially those in expansionary mode), which they can spend on other things, such as financial aid.

But a negative is that this housing separation between students from rich families and everyone else helps further widen class divisions in a time of yawning income inequality, which you can see all around you. Love those “gated communities’’! It does this in part by depriving middle- and lower-income students of much of the opportunity to mix with privileged students and gain access to their social and business connections. Residential segregation at colleges further consolidates the power of the permanent, hereditary upper class and reduces the sense of collective citizenship.

Chris Powell: Social Security benefits can and should be expanded

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How disappointing that the leadership of the Republican minority in the U.S. House has dismissed peremptorily Connecticut Rep. John B. Larson's legislation to keep Social Security solvent for a century while improving benefits. Though the bill seems likely to pass the House, given the Democratic majority there, it won't go anywhere in the Senate, where the majority is Republican, unless Republicans in the House support it.

Republicans complain that Larson's bill costs too much. But the increases that the bill would make in Social Security taxes are small and gradual, and much of the new revenue would come from higher incomes that now escape Social Security taxation. Besides, if taxing too much for Social Security is a problem, why do the Republicans seem to think that the forever war in Afghanistan is a necessity and a bargain?

Yes, as the Republicans complain, under Larson's bill poorer people would receive more in benefits than they contributed in Social Security taxes. But so what? Social Security is already largely a matter of income redistribution, just as all government itself in a progressive tax framework is redistribution. All private forms of insurance are redistribution, too. But few things government does are as compelling as Social Security.

Only military contractors benefit from Afghanistan. That is income redistribution too but Republicans don't complain about it.

Call Social Security welfare if you want, but it profoundly incentivizes and rewards work, for people earn benefits only through working or their relationship to someone who worked. It is a retirement savings plan and disability insurance policy that cannot fail as long as the United States endures. Larson pointedly asks: "Where in the private sector can you buy this package of benefits that is there for all Americans? You can't. It doesn't exist."

Further, if, as the Larson bill envisions, improved Social Security benefits prevent people from retiring into poverty, money circulating in the economy will increase, because poorer people will spend most of their benefit on necessities. Meanwhile, with fewer people retiring into poverty, fewer people will rely on other welfare benefits.

Of course, details of the Larson bill are arguable, particularly the levels of taxation and benefits. But the aging of the population is expected to make the Social Security Trust Fund insolvent by 2035 if its revenue isn't increased or benefits reduced, and then Social Security will be competing for ordinary appropriations every year with other government functions -- including the usual stupid imperial wars -- even as maintaining the social insurance system should have priority.

There is no disputing the demographics. They will make Social Security insolvent in less than 20 years unless something is done, and doing nothing means cutting benefits even as income inequality worsens. Will that really be the Republican plan?

xxx

WHERE ARE THE LIBERALS?: The office of Connecticut Atty. Gen. William Tong says it is working with the U.S. Justice Department's Antitrust Division to review the planned acquisition of United Bank by People's United Bank, which would sharply reduce competition in banking in central Connecticut and western Massachusetts. At least someone is paying attention.

But Governor Lamont and state legislators, even those who portray themselves as liberals, have nothing to say about this consolidation in the banking industry and the loss of many bank branches and hundreds of jobs. The trivialities liberal legislators applaud have little bearing on Connecticut, but preserving economic competition is vital.


Chris Powell is a columnist for the Journal Inquirer, in Manchester, Connecticut.

Still quaint

Menemsha Harbor.

Menemsha Harbor.

“Through the years this little fishing port (Menemsha, on Martha’s Vineyard) has retained its identity with the past. The wharfs where the fishing boats tie up have a crustiness about them that is unbeatable. The inlet, Menemsha Pond and Quitsa Pond, have that something special that comes from salt marshes on the east, little coves on the southwest, and a high bluff  and white sandy beaches on the west and north – they are so perfect even a full moon or a rising sun can hardly improve upon them.’

From “Welcome to Menemsha,’’ by Davis Taylor (1908-2002), a longtime Boston Globe publisher, in Arthur Griffin’s New England: The Four Seasons (1980)

Southern New England's polluted beaches

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From ecoRI News (ecori.org)

Nearly 60 percent of the 4,523 beaches tested nationwide last year had water pollution levels on at least one occasion that put swimmers at risk of getting sick, according to a new report by Environment America.

The report, Safe for Swimming?, looked at fecal bacteria levels at beaches in 29 coastal and Great Lakes states, as well as Puerto Rico.

“Swimming at the beach is a prime summertime joy for millions of Americans, but clearly we have more work to do to make sure water at all our beaches is safe,” said John Rumpler, Environment America’s clean water program director. “We must invest in water infrastructure that prevents pollution to ensure that America’s waterways are safe for swimming.”

Fecal bacteria can make people ill, particularly with gastrointestinal ailments. Common sources of this pollution include stormwater runoff and sewage overflows. Swimming in polluted water causes an estimated 57 million cases of illness annually, according to a 2018 study published in the journal Environmental Health.

This problem is widespread. In Illinois, for example, all 19 beach sites sampled exceeded the margin of safety for fecal bacteria recommended by the Environmental Protection Agency (EPA).

As for southern New England, here is what the report found:

Rhode Island: 54 of 129 beach sites sampled were potentially unsafe for at least one day in 2018. A sampling site at Easton’s Beach in Newport was potentially unsafe for 10 days, more than any other site in the state.

Massachusetts: 223 of 583 beach sites sampled were potentially unsafe for at least one day. A sampling site at Nahant Bay was potentially unsafe for 39 days.

Connecticut: 81 of 113 beach sites sampled were potentially unsafe for at least one day. A sampling site at Byram Beach in Fairfield County was potentially unsafe for six days.

Across the country, 2,620 beach sites exceeded the EPA margin of safety at least once last year. Of those, 605 locations were potentially unsafe in at least one-quarter of the bacteria tests. All told, there were 871 beach closures nationwide in 2018.

The 46-page report includes several recommendations to prevent bacterial pollution and keep beaches safe for swimming. Rain barrels, rooftop gardens, permeable pavement, and urban green space can all absorb stormwater runoff and help prevent sewage overflows.

“Our analysis of nearly 200,000 sampling results reveals threats to public health at beaches in every corner of the country,” said Gideon Weissman, of Frontier Group, which co-authored the report. “It's no longer enough to warn swimmers when beaches may be unsafe, especially when there are steps we can take today to reduce the threat of bacterial contamination in our waterways.”

David Warsh: From the West's 'culture of growth' to a culture of sustainability?

World's per-capital gross domestic product a shows exponential growth since the beginning of the Industrial Revolution.

World's per-capital gross domestic product a shows exponential growth since the beginning of the Industrial Revolution.

A Culture of Growth: The Origins of the Modern Economy (Princeton, 2016), by Joel Mokyr, of Northwestern University, is one of those obviously important books that nevertheless hasn’t received the reception it deserves, owing, perhaps, to its daunting erudition; more likely, to readers who thought they already knew the story of how the West grew rich.

For instance, for well over a year, the book has sat on an office shelf at eye level across the desk here at economicprincipals.com’s world headquarters in Somerville, Mass., along with three other books by Mokyr, and three closely related volumes by Deirdre McCloskey (who has a new book coming out), as well as a set of careful notes made by a friend, waiting for a week in which I had nothing else to do except tackle them. The New York Times didn’t review A Culture of Growth when it appeared; neither did The Wall Street Journal nor The New York Review of Books. Burnishing the brand of British exceptionalism, the Financial TimesThe Economist, and The Times Literary Supplement all did give it their attention.

Last month a review essay appeared, prepared by Enrico Spolaore, of Tufts University, for the Journal of Economic Literature, that locates Mokyr where he belongs.  He is in the vanguard of a movement among economists broadening the concerns of their discipline to include the influence of what we commonly call culture. (Spolare’s review elicited this Free Exchange column in The Economist last week.)

Examples of this deeper curiosity abound: in The Republic of Beliefs: A New Approach to Law and Economics (Princeton, 2018), by Kaushik Basu; in A Crisis of Beliefs: Investor Psychology and Financial Fragility (Princeton, 2019), by Niccola Gennaioli and Andrei Shleifer; in David Kreps’s Nemmers lecture, at Northwestern University,  Some Dimensions of Behavior with Which Economics Should Contend.Spolaore and research partner Romain Wacziarg are themselves major contributors to the literature:  In Fertility and Modernity, they construct a dataset of 275 European languages and dialects in order to compare what they call “linguistic distances” among European regions with changes in fertility rates. Not surprisingly, they find that social norms diffuse along cultural lines.

For a long time it has been apparent that something important happened in Europe after 1500 that did not happen elsewhere.  The recognition goes back at least to Max Weber’s 1905 book, The Protestant Ethic and the Spirit of Capitalism.  More recent debate began after Australian economist Eric Jones’s 1981 book, The European Miracle: Environments, Economies and Geopolitics in the History of Europe and Asia.  Then came Jared Diamond, Guns, Germs and Steel, in 1997, and David Landes, The Wealth and Poverty of Nations: Why Some Nations are So Rich and Others So Poor, in 1998.  Now Mokyr, and his cross-town Chicago counterpart McCloskey, have zeroed in on fundamental cultural values, especially in Bourgeois Equality: How Ideas, Not Capital or Institutions, Enriched the World, the third volume of her monumental trilogy.  The wheelhorse chapters in Mokyr’s book are devoted to two carefully defined and described “cultural entrepreneurs,” Francis Bacon and Isaac Newton, followed by accounts of the cultural diffusion and evolution of their ideas

To my mind, the greatest value of A Culture of Growth may turn out to be as a goad to reflecting on what more will be required to transform enthusiasm for growth to a culture of sustainability. At least that is the sense in which I am finally reading it now.  But that’s a topic for another day.

David Warsh, an economic historian and veteran columnist, is proprietor of economicprincipals.com, where this column first ran.

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Gold coasts

Damage along the shore of Westerly, R.I., after Hurricane Carol, which struck on Aug. 31, 1954.

Damage along the shore of Westerly, R.I., after Hurricane Carol, which struck on Aug. 31, 1954.

From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

Nice about-face by Bailey’s Beach Club, in Newport, which had initially tried to close a nearby roadside snack stand started by three very enterprising Rogers High School students (“not our kind, dear!’’), but then decided to support it after a GoLocal article reported on what seemed to be a case of snobbery and arrogance, arousing some brief public outrage. Still, the reaction to the oh-so-exclusive Bailey’s imperialism reminded me of what irritates a lot of us in a nation increasingly run for the benefit of the very rich: That most of the people at Bailey’s are materially or socially fortunate through little effort of their own but rather through the accident of being from rich families. The famous Lucky Sperm Club.

To read a GoLocal article on this entertaining controversy, please hit this link.

xxx

In another interesting coastal development, there’s a move underway to lift the prohibition on federal flood insurance for more than 900 homes, mostly owned by the wealthy, on the East Coast. Many of these homes should never have been built in flood-prone areas, now made ever more vulnerable by seas rising because of global warming. The proposed change would have taxpayers cover some or most of the cost of rebuilding fancy houses and would provide federal aid to fix such infrastructure as roads and bridges.

All wet at Bromfield Gallery

“Harpa’’ (acrylic ink and oil on canvas), by Kim Smith, in the show “WET!’’, at Bromfield Gallery, Boston, through Aug. 18. The juried show features 25 New England artists. The gallery explains that exhibition uses a wide range of media to explore the theme, “from the ocean to tears to eroticism.’’

“Harpa’’ (acrylic ink and oil on canvas), by Kim Smith, in the show “WET!’’, at Bromfield Gallery, Boston, through Aug. 18. The juried show features 25 New England artists. The gallery explains that exhibition uses a wide range of media to explore the theme, “from the ocean to tears to eroticism.’’

So drill off New England instead

— Photo by TheConduqtor

— Photo by TheConduqtor

From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

Fishermen opposed to proposed wind farms off the southern New England coast should send a research delegation to often stormy northwest Europe, where big offshore wind farms have co-existed with intensive fishing for years, with supports for the wind turbines acting as reefs that attract fish. Or maybe we should frack more for natural gas in Pennsylvania, blow up some more mountaintops for coal in West Virginia, or start drilling for oil and natural gas on Georges Bank to get the energy we need to keep the lights on? Those drilling platforms would take up less water than wind farms.


Barbara Gottlieb: Stop fracking ASAP

2016 march in Philadelphia. There’s extensive fracking underway in Pennsylvania.

2016 march in Philadelphia. There’s extensive fracking underway in Pennsylvania.

Science. Evidence. Facts. Do these even matter anymore in U.S. policy? They should — especially when it comes to issues that affect our health and environment, like fracking.

Concerned Health Professionals of New York and my organization, Physicians for Social Responsibility, recently released a remarkable compendium of research on the subject. It summarizes and links to over 1,500 articles and reports and has become the go-to source for activists, health professionals, and others seeking to understand fracking.

The new studies we looked at expose serious threats to health, justice, and the climate.

A 2018 study in the Journal of Health Economics, for instance, found that the babies of Pennsylvania mothers living within 1.5 miles of gas wells had increased incidence of low birth weight. Babies with low birth weight (under 5.5 pounds) are over 20 times more likely to die in infancy than babies with healthy birth weight.

Babies exposed in utero to fracking are likely to face additional challenges throughout their lives. They may suffer long-term neurologic disability, impaired language development and academic success, and increased risk of chronic diseases, including cardiovascular disease and diabetes.

Other researchers are finding that fracking wells and associated infrastructure are disproportionately sited in non-white, indigenous, or low-income communities.

A study published this year in Ecological Economics analyzed the socio-demographics of people living near drilling and fracking operations in four high-fracking states: Colorado, Oklahoma, Pennsylvania, and Texas. It found strong evidence that minorities, especially African Americans, disproportionately live near fracking wells.

They don’t just face disproportionate exposure to toxic emissions, leaks, and spills. They also have fewer resources — like health insurance, medical services, or income security — that would help them protect their health.

But you don’t have to live near wells and pipelines to be at risk. We all face harm from fracking’s impact on the climate.

So-called “natural gas” is 85-95 percent methane, a short-lived but highly potent greenhouse gas. Over its first 20 years in the atmosphere, methane traps about 86 times more heat than carbon dioxide. That 20-year timeframe matters: Scientists tell us that’s about the time we have to slash our greenhouse gas emissions and begin pulling carbon out of the atmosphere.

Unfortunately, as the research we collected finds, methane leakage rates from drilling and fracking operations have “greatly exceed” earlier estimates. A 2018 analysis of methane leaks across the U.S. found leakage rates to be 60 percent higher than reported by the EPA. A 2019 study in southwestern Pennsylvania found some gas emissions to have been underreported by a factor of five.

Overall, how bad is fracking? The Compendium states that “public health risks from unconventional gas and oil extraction are real, the range of adverse environmental impacts wide, and the negative economic consequences considerable.”

It concludes: “Our examination of the peer-reviewed medical, public health, biological, earth sciences, and engineering literature uncovered no evidence that fracking can be practiced in a manner that does not threaten human health.”

The logical conclusion is that, for health, justice, and a livable world, the time to stop using fracked gas is now.

Barbara Gottlieb is the director for environment & health at Physicians for Social Responsibility, www.psr.org. She participated in the pre-publication review of the Compendium.

Building in N.E. coastal risk zones continues apace

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From ecoRI News (ecori.org)

As the country’s coastal communities continue to build homes in flood-risk zones, a new nationwide analysis by Climate Central shows that nearly 20,000 homes built in the past decade are at significant risk of chronic coastal flooding by 2050.

If greenhouse-gas emissions go unchecked, more than 800,000 existing homes worth $451 billion will be at risk in a 10-year flood by 2050, according to Ocean at the Door: New Homes and the Rising Sea. Those numbers jump to 3.4 million existing homes worth $1.75 trillion by 2100.

The analysis paired Zillow’s housing data with Climate Central’s sea-level rise expertise to identify the number of new homes — and homes overall — in low-lying coastal areas. It then projected how many will become exposed to chronic ocean flooding over the coming decades, depending on the choices the world makes regarding greenhouse-gas pollution. It expanded on analysis done last year that showed some 386,000 U.S. homes are likely to be at risk of regular annual flooding by 2050 and that new homes are being built at striking rates in areas that face high risks of future flooding.

The recent analysis found that Connecticut (more than three times faster), Rhode Island (twice as fast), and Massachusetts are developing coastal risk zones more quickly than safer areas.

A third of the country’s coastal states have seen higher housing growth rates inside the 10 percent flood-risk zone than outside it.

As sea levels rise, the intermittent floods that coastal communities now experience once a decade on average are projected to reach farther inland than they do today. Those floods can damage and devalue homes, degrade infrastructure, wash out beaches, and interrupt transportation systems. They also put homeowners, renters, and investors in danger of steep personal and financial losses.

The results are clear. If the world makes moderate cuts to greenhouse-gas emissions — roughly in line with the Paris Agreement, whose targets the international community isn’t on track to meet — some 17,800 existing homes built after 2009 will face an at least 10 percent flood threat each year, on average, by 2050. The figures for 2100 are more than two times higher, and more than three times higher if climate pollution grows unchecked.

“For homebuyers over the next few years, the impact of climate change will be felt within the span of their 30-year mortgage,” said Skylar Olsen, Zillow’s director of economic research and outreach. “Without intervention, hundreds of thousands of coastal homes will experience regular flooding and the damage will cost billions. Given that a home is most people’s largest and longest-living asset, it takes only one major flood to wipe out a chunk of that long-growing equity. Rebuilding is expensive, so it’s doubly tragic that we continue to build brand new units in areas likely to flood.”

Coastal communities will encounter the impacts of sea-level rise to greatly varying degrees, depending on the local rate of rise, local tides and storms, the potential future development of coastal defenses, and the flatness of the landscape and where homes are built within it. Some major coastal cities sit high enough above sea level that the biggest hit will be to their beaches. Others will suffer more far-reaching and damaging effects.

Florida would have the most homes in the zone at risk from sea-level rise and 10-year floods by 2100 (1.58 million), followed by New Jersey (282,354), Virginia (167,090), Louisiana (157,050) and California (143,217) — assuming levees and other infrastructure defenses hold and emissions continue unchecked.

What’s more, 24 cities including New York, Tampa and Virginia Beach have built at least 100 homes in that risk zone since 2009.

“In many states, building on land projected by 2050 to face chronic flood risks has outpaced development in safer places,” said Benjamin Strauss, Climate Central’s CEO and chief scientist. “Failure to control climate pollution will lead to faster-rising seas and bigger coastal risk zones, but building a cleaner-running economy can still reduce these consequences.”

Flooding in    Marblehead, Mass   ., caused by Hurricane Sandy on Oct. 29, 2012

Flooding in Marblehead, Mass., caused by Hurricane Sandy on Oct. 29, 2012

Judith Graham: How to talk to seniors, families before surgery

— Photo by I Craig

— Photo by I Craig

From Kaiser Health News

The decision seemed straightforward. Bob McHenry’s heart was failing, and doctors recommended two high-risk surgeries to restore blood flow. Without the procedures, McHenry, 82, would die.

The surgeon at a Boston teaching hospital ticked off the possible complications. Karen McHenry, the patient’s daughter, remembers feeling there was no choice but to say “go ahead.”

It’s a scene she’s replayed in her mind hundreds of times since, with regret.

On the operating table, Bob McHenry had a stroke. For several days, he was comatose. When he awoke, he couldn’t swallow or speak and had significant cognitive impairment. Vascular dementia and further physical decline followed until the elderly man’s death five years later.

Before her father’s October 2012 surgery, “there was not any broad discussion of what his life might look like if things didn’t go well,” said Karen McHenry, 49, who writes a blog about caring for older parents. “We couldn’t even imagine what ended up happening.”

It’s a common complaint: Surgeons don’t help older adults and their families understand the impact of surgery in terms people can understand, even though older patients face a higher risk of complications after surgery. Nor do they routinely engage in “shared decision-making,” which involves finding out what’s most important to patients and discussing surgery’s potential effect on their lives before setting a course for treatment.

Older patients, it turns out, often have different priorities than younger ones. More than longevity, in many cases, they value their ability to live independently and spend quality time with loved ones, according to Dr. Clifford Ko, professor of surgery at UCLA’s David Geffen School of Medicine.

Now new standards meant to improve surgical care for older adults have been endorsed by the American College of Surgeons. All older patients should have the opportunity to discuss their health goals and goals for the procedure, as well as their expectations for their recovery and their quality of life after surgery, according to the standards.

Surgeons should review their advance directives — instructions for the care they want in the event of a life-threatening medical crisis — or offer patients without these documents the chance to complete them. Surrogate decision-makers authorized to act on a patient’s behalf should be named in the medical record.

If a stay in intensive care is expected after surgery, that should be made clear, along with the patient’s instructions on interventions such as feeding tubes, dialysis, blood transfusions, cardiopulmonary resuscitation and mechanical ventilation.

This is far cry from how “informed consent” usually works. Generally, surgeons explain to an older patient the physical problem, how surgery is meant to correct it and what complications are possible, backed by references to scientific studies.

“What we don’t ask is: What does living well mean to you? What do you hope to be able to do in the next year? And what should I know about you to provide good care?” said Dr. Ronnie Rosenthal, a professor of surgery and geriatrics at Yale School of Medicine and co-leader of the Coalition for Quality in Geriatric Surgery Project.

Bob and Marjorie McHenry pose with their daughter Karen McHenry at their 50th anniversary party in 2009. Bob McHenry had a stroke during an operation in 2012 and was comatose for several days after the procedure. When Marjorie fell and broke five ribs in fall 2017, she decided against surgery after consulting with the hospital’s palliative care team.

Rosenthal tells of an 82-year-old patient with early-stage rectal cancer. The man had suffered a stroke 18 months earlier and had difficulty walking and swallowing. He lived with his wife, who had congestive heart failure, and had been hospitalized with pneumonia three times since his stroke.

Rosenthal explained to the man that if she operated to remove the cancer, he might land in the ICU with a breathing machine and then end up at a rehabilitation facility.

“No, I don’t want that; I want to be home with my wife,” Rosenthal recalled his saying.

The man declined the surgery. His wife died 18 months later, and he lived another six months before he had a fatal stroke.

Surgeons can help guide discussions that require complex decision-making by asking five questions, according to Dr. Zara Cooper, associate professor of surgery at Harvard Medical School:

How does your health affect your day-to-day life? When you think about your health, what’s most important to you? What are you expecting to gain from this operation? What health conditions or treatments worry you most? And what abilities are so critical to you that you can’t imagine living without them?

Cooper recalls an 88-year-old man seriously injured in a car crash arriving in the emergency room several years ago.

“When we started explaining to his family what his life would be like — that he would be highly functionally dependent and not able to live independently again — his wife said that would be absolutely devastating, especially if he couldn’t ski,” Cooper said. “We didn’t even anticipate this was in the realm of what someone this age would want to do.”

The family decided not to pursue treatment, and the patient died.

Sometimes surgeons make the misguided assumption that older patients want to follow recommendations rather than having input into medical decisions, said Dr. Clarence Braddock, professor of medicine at UCLA. In focus groups, 97% of seniors said “I prefer that my doctor offer me choices and ask my opinion,” according to research Braddock published in 2012.

Yet in another study involving older adults, Braddock found that orthopedic surgeons rarely discussed the patient’s role in decision-making (only 15% of the time) or assessed the patient’s understanding of what surgery would entail (12% of the time).

At the University of Wisconsin-Madison, Dr. Margaret Schwarze, an associate professor of vascular surgery, has developed a tool called “best case/worst case” to help surgeons communicate more effectively with older patients.

“The idea is to tell the patient a story in terms they can understand,” Schwarze said.

Instead of citing statistics on the risk of pneumonia or infection, for instance, a surgeon would explain what might happen if things went well or badly. Would the patient be in pain? Would she need nursing care? Would he be able to return home and do things he liked to do? Would she land in the ICU? Would he be able to walk on his own?

A similar range of possibilities is presented for a treatment alternative. Then the surgeon identifies the most likely outcomes for surgery and the alternative, based on the patient’s circumstances.

“Going through a major operation when you’re older is going to change your life,” Schwarze said. “Our goal is to help older patients imagine what these changes might look like.”

Because of her father’s experience, Karen McHenry was cautious when her mother, Marjorie McHenry, fell and broke five ribs in fall 2017. At the hospital, doctors diagnosed significant internal bleeding and a collapsed lung and recommended a complicated lung surgery.

“This time around, I knew what questions to ask, but it was still hard to get a helpful response from the surgeons,” Karen said. “I have a vivid memory of the doctor saying, ‘Well, I’m an awesome surgeon.’ And I thought to myself, ‘I’m sure you are, but my mom is 88 years old and frail. And I don’t see how this is going to end well.’”

After consulting with the hospital’s palliative care team and a heart-to-heart talk with her daughter, Marjorie McHenry decided against the surgery. Nearly three years later, she’s mentally sharp, gets around with a walker and engages in lots of activities at her nursing home.

“We took the risk that Mom might have a shorter life but a higher quality of life without surgery,” Karen said. “And we kind of won that gamble after having lost it with my dad.”

Judith Graham is a Kaiser Health News reporter.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham


Llewellyn King: A reality check for some Dems on fixing America's awful health-care 'system'

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The Democrats on the left of the party, exemplified by Elizabeth Warren, Bernie Sanders and Kamala Harris, are running away with the health-care debate.

The problem for those who, like myself, want to see health care extended and rationalized is that the real goals of reform have been abandoned for “universal health care” as an ideological and political goal; add a political prejudice against corporations and the idea of the most health care for all of the people gets lost, as it did in the debates.

There should be only two goals in health-care reform: bring down the cost and see that everyone is covered.

We in the United States have the costliest medicine on earth. We also have the spottiest and most risible coverage. We spend over 18 percent of our gross domestic product on health care, nearly twice the cost of health care in other advanced countries like Britain, France, Germany and Holland. That is a huge cost, making us a less-competitive country. It comes not from medicine but rather from inefficient management.

We are a nation which venerates its business culture, but in health care, as it stands, we are protecting inefficiency as though it were a system. There are better ways, short of upending the whole structure, as Warren, Sanders and Harris would like to do, of fixing the system.

Serious reform is seriously needed.

Children’s National Hospital , in Washington, D.C., for example, I am told, employs 150 people just to deal with the insurance companies, negotiating payments, securing permission for procedures and protesting disallowances. Presumably, there are as many people in the insurance companies on the other side of these transactions. None of this huge personnel deployment is delivering health care or serving medicine. They are engaged in health care’s equivalent of a souk -- bargaining care for money. It should change because it is enormously wasteful, let alone because it fails in its mission: delivering care to the sick.

Remember the old military saw: We had to destroy the town to save it.

In full bay at the Democratic debates in Detroit, Warren, Sanders and Harris were in competition both to junk all private health insurance and to trash the companies that provide it.

I have spent three decades studying health-care delivery. While I am an unalloyed admirer of the National Health System (NHS) in the United Kingdom, it is not for the United States. Not now.

I know the NHS: It has treated my family well since its inception and, briefly, myself. But I do not think we can trash what we have here root and branch and install a duplicate NHS. We have too much that would have to be changed; too large a new bureaucracy would have to be created.

I am in favor, though, of the government as a payer of last resort for those who cannot get coverage and those for whom treatment is too expensive for the insurer.

We need to regulate medicine and to take the uncertainty out of it. That uncertainty extends from patients who never know when they will be sideswiped by an out-of-network procedure and routine providers, to the hospitals which need to know what they will be paid. Coverage should be guaranteed, not negotiated.

I used to own a newsletter publishing and conference company in Washington. I provided health insurance, which cost me in well-being as well as dollars. The costs went up relentlessly and coverage was problematic. My top aide came down with a rare cancer. The treatment was fine, all paid for, but the post- treatment painkillers were not allowed. I tried to persuade the insurer -- after all, we were a 20-strong group. They would not be moved. So my aide, who is French, had her sister send the medications from France, where she could get them for free as a citizen.

If we can get the horror of negotiation out of the system, care would be better, and costs would fall.

I am told that the future might be based on what already is working well with Kaiser Permanente, an integrated managed care consortium that insures, provides doctors and hospitals in the package.

It is worth a look -- before we start shelling the system to save it.

Llewellyn King is executive producer and host of White House Chronicle, on PBS. His email is llewellynking1@gmail.com and he’s based in Rhode Island and Washington, D.C.


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