Tag: bureaucracy

High-Speed Rail Vital for PWD and the Nation; Why Have the Promises Evaporated?

Posted by nickdupree – March 28, 2013

High-Speed Rail (HSR) would help everyone and boost the economy but would disproportionately benefit PWD—people with disabilities—because for a significant percentage of us, it’s difficult to impossible to use the airlines. And with the TSA confusing the grit you get on your hands operating a manual wheelchair with “bomb residue” again and again, fewer PWD will bother (President Obama mentioned the TSA-free joy of rail himself). High-speed rail has become a necessity for the social and economic relations of Americans, but sadly the promises the Obama Administration has made on high-speed rail have not been fulfilled.

I want high-speed rail that goes up and down the Eastern United States at 500mph so I can go from NYC to my family in Washington DC and Norfolk.

Imagine the economic benefit HSR could bring to the United States and Canada, if we had two-hour trips from NYC to Toronto or four-hour trips to Montreal or Ottawa! Imagine the ability of West Virginians to zip in an hour to Washington DC for jobs that simply don’t exist in Appalachia! Imagine the life-blood this would be for tech start-ups, when suddenly software engineers and DIY white hat hackers can whoosh in from Quebec to Boston or NYC for in-person collaboration! Imagine people able to work in New York but live in relatively-inexpensive Cleveland. That kind of economic game-changer is necessity. That kind of hope is a necessity, and President Obama really tapped into that…

…and then did absolutely nothing.

That’s right, nearly three years after the sweeping promises about Chinese-style bullet trains, not a single yard of HSR has been put down. We didn’t get the high-speed bus system The Onion proffered as a post-austerity alternative either. :P

The below AC 360 segment, “Keeping Them Honest,” explains where the billions in funding Congress appropriated for high-speed rail went. It all went to slow rail. As is also true of the news stories that I share on Twitter, I don’t always agree with everything in a given article I post, and in the case of this “Keeping Them Honest” segment, I don’t agree with CNN reporter Drew Griffin that allocating federal funding to make extant Amtrak routes less slow is “a boondoggle,” nor is the general thrust of the report that the entire thing is a shameful waste of taxpayer dollars representative of my point of view. I know people who use that very Vermont route, and those routes need funding too. But Drew Griffin is RIGHT that the Obama Administration and President Obama himself promised Americans high-speed rail, on camera, numerous times, and so far it’s a promise they’ve not kept; the only project the U.S. Department of Transportation (DOT) allotted HSR funding for that can actually be construed as high-speed rail, is the California High-Speed Rail Authority (CHSRA) project to connect San Francisco to Los Angeles with a one-way travel time of at least 2 hours and 40 minutes, and it’s been bogged down with NIMBY (Not In My Back Yard) lawsuits and red tape so severely that not a single track has been laid. He’s RIGHT to ask, “you’ve promised us bullet trains like the Europeans and Japanese have had since the 1980s; where’s the high-speed rail?” Why can’t we have nice things?

This high-profile failure to deliver public transportation technology that Americans need should trigger much more discussion. Why is the executive branch unable to deliver on its promises, even after Congress appropriated the funding necessary? We need to discuss the general direction here, because we’re headed for eight years of Democrats running the executive branch and still our trains are stuck at 1950s speeds, we have a 1950s power grid, and our existing transportation infrastructure (rail, roads, highways, bridges, airports, ports) got a D+ for 2013 from the American Society of Civil Engineers (ASCE). At least one of America’s bridges may crumble this year and lead to a mass casualty event. It feels like MALAISE.

The California High-Speed Rail Authority (CHSRA) is now evidently so chastened by ridiculous NIMBY lawsuits arguing the deleterious effects of high-speed trains on “aesthetics,” that they’ve begun to move forward with a pared down, slow-speed rail plan that they promise is only temporary (the “blended plan,” they call it). The founder and former head of CHSRA has now come out against this plan, since it doesn’t meet the Prop 1A ballot initiative’s requirements for true high-speed rail. If truly rapid transit for the masses, and all its social and economic benefits, can be thwarted long-term by some wanker micro-minority concerned about—not environmental impact, since rail reduces pollution vs. cars and buses—aesthetic impact alone, then that says something very distressing about where we are headed.

I don’t usually blog about transportation, but I want this space to showcase writing about the unreported and under-reported stories, amplify the voices of the unrepresented, and this issue hasn’t gotten a third of the coverage and discussion it warrants. Our leaders make sweeping, epic promises and too often the media doesn’t follow up in any sustained way. I do wish the private sector would lay high-speed rail and bring in the newest Japanese bullet trains, a mega corporation would definitely get more media discussion than the CHSRA, but they would likely give up after a week of the BS posed by regulatory hurdles, intractable NIMBYites, and the red tape nightmare of building across multiple state and county jurisdictions.
We have to put it out there to the people, over and over again, that we need current technology for high-speed rail, we need truly rapid transit, widely available and accessible, for many reasons, but freedom of movement for the poor and disabled populations who have the greatest difficulty accessing transportation at the top of the list.

Nick

The Social vs. Medical Model of Disability, Communities Will Be Forced To Choose

Posted by nickdupree – April 7, 2011

You may or may not know about the medical model and the social model of disability.

Many disabled people have rejected this model. From the Taxi Driver Training -- Democracy, Disability and Society Group, UK

The social model of disability sees disabilities as normal aspects of life, not medical problems requiring "treatment," with the real problems coming from inaccessibility and ignorance of disabled people. From the Taxi Driver Training -- Democracy, Disability and Society Group, UK

I wanted to talk about the social model of services and supports for people with disabilities, and barriers to implementing it.

When you think about disability internationally, most disabled people in countries around the world are taken care of by their own families and their own communities. In Alabama, where I’m from, and in many of the poorer states, they didn’t get the medical model at all until federal funding in the 1960s. Prior to that, all you had was a kind of quasi-social model, with families and neighbors taking care of their disabled children, the same way they did in the 19th century and from time immemorial. A new social model of services and supports would essentially work like an enhanced version of that, with disabilities normal phenomena that communities live with and provide for.

In the first world countries, as families are working almost entirely outside of the home, they have no recourse but to use government services to help take care of their disabled children and adults. In Alabama, the attitude is that the most harsh, spartan medical model is all they can afford, and that they can’t afford to innovate. They have missed an opportunity to save money by re-imagining a social model that would put the power back in the hands of families and people with disabilities, instead of forcing them to spend on treatments that the medical model wants for them.

Across the country, budget cuts are removing the medical model more and more from our lives, because the states can no longer afford the kind of medical services that they’ve been paying for. The medical model won’t be the force it has been without enough public funding. So there’s more need than ever to implement a new social model of services and supports. In one of the conferences that I attended (TASH Boston ‘02) there was a session on what drives people to put their loved ones into nursing homes. And the number one reason found in studies was that when someone becomes incontinent of bladder and bowel, the family doesn’t want to deal with it, and puts them in a facility. There was one story where a mother wanted to put her autistic son in a facility just because he couldn’t figure out how to zipper his pants, though he could otherwise engage in self-care. This is the institutional bias, up close and personal, and it is ridiculous. We can no longer afford to put people with disabilities in segregated, medical model institutions. The funds saved by turning the institutional bias on its head and closing more of these terrible, outdated, freedom-killing institutions is great. We can’t afford these awful dinosaurs financially, and we can’t afford it in the human toll, in the human potential and spirits that are locked up.

To escape that fate of being put away forever in a nursing home, I had to fight Alabama Medicaid policies that would cut off home care services at age 21. My campaign, Nick’s Crusade, led to the Dupree v. Alabama Medicaid lawsuit, which used the Olmstead decision to end the practice of Alabama cutting off ventilator dependent people from in-home services once they turned 21. It was a victory that helped half a dozen people stay in their homes, but it didn’t solve the underlying problem, that even in the home, the medical model of home nursing care tends to segregate, restrict and limit the liberty and potential of people with disabilities.

I ended up having to leave college because of problems with home nursing care, and eventually I began to outlive my family’s ability to take care of me, and ended up relocating to New York City in August, 2008. Because of difficulties getting home care approved and started, home nursing agencies that are dysfunctional and cruel, and relentless ablism faced by me and my partner Alejandra, my first 378 days in New York were spent in a city rehab hospital. It was my first stent in a facility, and I learned a lot about the system that keeps unnecessary institutionalization going and told the world in The First Video Blog Series From Inside An Institution In History. Make especially sure to watch my videos What Life In An Institution Is Really Like, And Why This Entire Model Should Be Replaced and Too Many Setbacks To Count (about the barriers and delays to getting home, with music).

Because Alejandra and I love each other, we made the decision to spend our lives together, as many people with and without disabilities do. However, most people with disabilities living in the U.S. run into the so-called “marriage penalty” if they receive federal Social Security benefits, which are reduced by one-third if two recipients marry. Choosing to declare our commitment to each other despite this policy, we held a commitment ceremony in Central Park on June 6, 2010. It was also an opportunity for others in the community to learn about and share their experiences with this injustice.

Getting the supports needed to maintain my health and safety, attain freedom to access the community and resume college remain problematic. I write and draw webcomics, such as Theodore Roosevelt and the Rough Riders vs. Zombies. I was going to show my work from a table at the MoCCA Festival, and ended up canceling because we didn’t have the help for getting me up in the chair and out to the festival. For me as a disabled man, “freedom,” means that I have good caregivers around me that can help me do stuff. Without those people, I’m stuck in my room at best, and, at worst, dead.

Nurses, personal care attendants, and other home caregivers will always remain enormously important in any model because in first world countries the cost of living is high, and thus the people doing the bulk of the care will be the ones who can do it without losing their apartment. Paid supports should be budgeted by the disabled person (see individualized budgets and the Cash & Counseling program) so that both the caregivers and the patient aren’t constantly battling middlemen–agencies and Medicaid, and so the patient can give their best staff higher pay and bonuses. This essay isn’t meant diminish the importance of nurses and PCAs but to re-imagine them as part of a support community that form around people with disabilities; with families and communities that refuse to shelve their people in prison-like nursing facilities, that refuse to use a strict, heartless medical model inside the home, that say NO to materialism and profiteering, and instead focus on care and caring. Personal care is incredibly intimate and sensitive, caregivers see and touch and care for wounds, deformities and vulnerabilities that no one else sees, this is soulful and special work; it should never be callously commodified or turned into a cold assembly line in a nursing facility. The people who are good at going into someone’s home and making them clean, comfortable, giving them care and freedom, are very special people. In a new social model, friends and neighbors of the disabled person partner with and lend their support to these special caregivers, helping them and assisting them to assist their patient. The caregivers in turn helping the friends to help their patient. They care about each other and collaborate to help the disabled person. The community loves and supports each other.

Relying on Medicaid to give me ALL the assistance needed to live a real life in the community will always be difficult as long as Medicaid is locked-in to the medical model. It’s near impossible without friends and volunteers in your community lending some support. What is needed is the social model: normalization of disability: for society at large to start seeing people with disabilities as equal members of families and communities, instead of undue burdens. If someone in the community had cared about the kid who couldn’t manage the zipper on his pants, he wouldn’t have been at risk of institutionalization at great cost to his community. If the community would give their time and love more, we’d need Medicaid, the increasingly dark, Kafkaesque bureaucracy that pays for services for disabled people, less.

There are plenty of ways for the community to support people with disabilities. When I was hospitalized for several months in early 1992, Bettie Hudgens, the founder of the Communications department at Spring Hill College, where my mom taught, created a sign up sheet so that volunteers would visit me every day, so I would have someone checking in on me during the hours mom was teaching. The signup sheet allowed the community to organize around me so that every day was covered. We need that kind of community building now more than ever.

Communities will eventually be forced to choose, will they pay more and more for Medicaid as its red tape continues to render it hilariously dysfunctional like a Soviet department, or will friends and neighbors pitch in to help the elderly get in and out of bed, and change soiled clothes so they wouldn’t have to be segregated in institutions, so their people with disabilities will have less involvement with the heartless Medicaid bureaucracy and be less exposed to the whims of the politicians that fund them. It’s up to us to implement a new social model, as the old models begin to collapse.

Nick

Nick’s Essay on America’s Decline, with Big Solutions (long)

Posted by nickdupree – May 15, 2010

I’ve been away for quite some time, I know, but I haven’t stopped thinking about public policy and the way things are going.

They aren’t going well. I followed the health care reform debate with a magnifying glass throughout, and came away deeply disgusted in both the final product and the process that made that sausage.

We desperately needed SERIOUS reform to the United States’ health care non-”system”; we’re in the richest country on Earth, but among OECD nations, our health care is at the back of the pack. No country with our level of wealth has our level of dysfunction in basic health care.

Instead of “the change we need,” what we got when Congress was done kowtowing to big insurance donors and passed the damn thing, was incremental change to half the health care industry (the private insurance market) while leaving the half the government actually runs, Medicaid and Medicare, nearly untouched. The goal of the Obama reforms is to give more Americans access to the health insurance market, more people buying insurance, with subsidies to help the poor afford private insurance. The health insurance industry stands to rake in BILLIONS! I was devastated with disappointment.

Meanwhile, the frenzy on the right wing about this bill (which was nearly a straight copy and paste of the 1993 Republican health care bill (full text of that bill, see for yourself) taking us to “socialism” are patently absurd! I’m like “really? The first thing communists do when they take over a country is enact tepid, insurer-friendly reforms that set up a free market exchange so more people can buy insurance plans? Seriously?” A volcano of right-wing rage exploded, including dozens of death threats and some vandalism across the country. How can anyone take the Tea Partiers and Glenn Beck seriously that health care reform is anything but weak-kneed incrementalism?

The Tea Party is more disconnected from reality than any political movement I’ve ever seen, and yet, they seem to be the only major grassroots force out there and their impact is unavoidable. They’re protesting more private insurance as socialism, railing against the lowest income taxes since the 1920s as communist tyranny (simultaneously, the largely graying group opposes changes in entitlements–”get the government out of my Medicare”) and now that they’re doing the one thing that Republican politicians really care about, picking off incumbents, you’re going to see the GOP tilt even more toward the radical fringe (a terrifying prospect).

Real sign, real Tea Partiers. Medicare is a government-run program.

Since the Tea Party guys’ claims have little relationship to reality, and none of them took to the streets when George W. Bush took us from record surpluses to record deficits, centralized power and forever gutted the Bill of Rights in the name of the War on Terra, the Tea Party has to be about something else. You never see the huge, angry backlash and anti-government “patriots” in funny hats and militia terrorists like McVeigh come out of the woodwork when THEIR party is in power! I’m guessing the root of the dispute here is the right-wing’s belief that government shouldn’t have the right to interfere in the market AT ALL, and add in some good ol’ American racial panic when the multicultural Democratic party took over from the virtually whites-only Republicans. Expect another McVeigh-style attack before Obama leaves office (there have already been several shooting rampages, including one targeting religious liberals at a Unitarian church, one targeting policemen for “gonna take our guns,” and one by a long-time rightist fringer targeting Jews at the National Holocaust Museum in DC).

All that furor against the health care reform bill, while, of course, from the disability rights perspective, Obama’s reforms don’t go nearly far enough, because they only make meaningful changes in private insurance, not Medicaid and Medicare, which most of us with disabilities rely on for our care.

Medicaid and Medicare are BADLY broken and rapidly going bankrupt, but aside from expanding eligibility so that more people will be crowding already scant Medicaid resources, nearly NO changes are being made there. The home care reforms I’ve devoted a decade to are not in the bill; America’s long-term care programs remain frozen in 1965, with government continually making expensive, antiquated segregation in nursing homes THE ONLY OPTION for the disabled, including children and young adults. The horribly dysfunctional patchwork of Medicaid waivers that I rail against? Despite years of demands for change from many quarters, including the National Governors Association, those injustices will remain firmly intact, untouched by “comprehensive health care reform.” People like me will continue struggling to wring bad care from what’s left of Medicare and Medicaid; our lot will not improve at all after “Health Care Reform” takes effect. I am fighting this battle every day, and the problems with hospitals closing due to inadequate payments from Medicaid, not being able to find doctors who still take Medicaid patients, and more, just continue to escalate for me.
Meanwhile, the insular Washington leadership is curiously detached and unaware of what’s happening to their own Medicaid and Medicare programs right under their noses. President Obama made me sick when, during the health care reform “summit,” Congressman Peter Roskam (R – Illinois’ 6th district) asked him, “how can we expand Medicaid when in some counties, NO doctors that take Medicaid are left standing?” and the gist of Obama’s response was “my word, what is this that you speak of my good fellow? if this is so, we can look at raising reimbursement rates!” Everyone knows that they’ll never hike Medicaid funding, and that’s why so many in Congress sought special provisions in the bill (e.g. “The Cornhusker Kickback”) for the feds to cover their states’ new unfunded mandates to expand eligibility to millions of additional people. These expansions are not going to go well, particularly in poorer states, especially since the “kickbacks” to soften the fiscal blow were all removed from the bill with reconciliation.

The failure to even attempt changing the glaring problems with Medicaid and Medicare has left me more jaded and frustrated than ever, to the point [b]I can no longer call myself a Democrat[/b]. Especially since I know that Congress exhausted itself scraping through this tinkering with private insurance, and most likely won’t have the political will or sense of urgency to revisit health care issues for another 10, 20 years. I hate being stuck with our dysfunctional Medicaid system but that’s what people with disabilities are, stuck.

While some pundits hailed the passage of health care as a colossal foreign policy victory, proving America can tackle huge issues, marking our “comeback” as problem-solver on the world stage, I see the opposite. I see a government that lacks the dynamic, bold decision-making capability that these ultra-competitive times demand, a Congress that always cops out or kicks the can down the road in the face of huge problems. I see an America so paralyzed by corruption and red tape that we’ll never catch up with competitors (people in India have already stuck a fork in the U.S., considering the Chinese their only real rival for economic dominance at this point).
Referring to China, I’ve often heard President Obama use the rallying cry, “why can’t we be the world leader in technology again?! Why can’t we have the fastest trains in the world?” Well Mr. President, I would answer him, we will never build trains and train tracks faster than China, because we have so much “environmental impact study” and “archeological impact study” red tape, followed by years of hearing lawsuits from anyone who doesn’t like the project, that it takes an average of 10 years to get any major transportation project off the ground, much less completed. China, meanwhile, simply makes a decision on future train projects, then enforces it by any means necessary. How can we compete with that given our bureaucracy?

While those panicked about executive power right now can take a sigh of relief, because presently it seems Obama can’t even take a $#!T without 60 votes from the Senate, I worry that, before long, fierce foreign competition, falling standards of living, plus a completely paralyzed Congress will lead the American people to demand a dictatorship. Another sudden economic crash, or, G-d forbid, successful terrorist attacks (by Islamist nutbags or another McVeigh) and I fear that the Republic will gasp its last gasp.

The only real solutions are solutions as big as the problems, pushed through by reform groups that aren’t just as dysfunctional as the institutions they’re fighting.

Big Solution #1: Ban campaign contributions (bribing) to public officials, as this has limited access to the halls of power ONLY to moneyed interests, as well as fostering a culture where those who spend more time working for the people than working on fundraising are immediately replaced by candidates with backing from deep-pockets, leaving only self-interested scoundrels remaining. Free speech must be immutable, overturn all McCain-Feingold restrictions on when and where and how candidates can advertise and get their message out, independent expenditures by corporations, unions, advocacy groups and private citizens are unfettered, you can say whatever you want, whenever you want with your free speech, because that’s what the 1st Amendment guarantees–you’re just not allowed to bribe public officials with campaign contributions and rig the system. Campaigns will be publicly financed like in Canada, the UK, and most of Europe. Speech is speech. MONEY IS NOT SPEECH!

Big Solution #2: Breaking the Duopoly is crucial, but WILL NOT happen without a change in the Constitution to allow Proportional Representation via STV (“Instant Runoff Voting,” AKA Single Transferable Vote, as is done in Australia, New Zealand, Republic of Ireland) to bring more parties into Congress. Allowing more parties will enable more principled views to be expressed (because, for example, if you want less intrusive government and less taxation, you won’t have to vote Republican for the tax cuts and get warrantless surveillance, anti-gay crap and anti-immigration laws too as part of the package, instead, you can vote for a party that closely matches your views). More parties also mean regional parties representing genuine regional people’s interests get into the mix. And parties would have to work together to coalesce into viable majority coalitions, and would have to curb the extremist nonsense to keep their coalitions together. Overall, Proportional Representation allows for a much, much healthier democracy, whereas currently we have the opposite of healthy democracy, the Duopoly nearly always wins 100% control of the House and Senate with the support of as little as 20-25% of eligible voters, at the cost of all other parties and their viewpoints.

Big Solution #3: This is my most radical view, but failing Solution #2, maybe we could be far more functional as a people and be much better represented, plus have no more imperialist ventures sapping our wealth, if we were to make a new version of the old Articles of Confederation for the new Information Age that separates the country into 6 or so federated regional powers (see: superstates) to avert any FURTHER deadlock, dysfunction, or civil war (each new state under parts of the current Constitution they elect to have, but empowered to each craft very different rules, based on their shared culture, for how society should work). I’m talking about ending the United States as we know it, replacing it with a federation of nearly autonomous federated republics named “the United Federation of America” (UFA! UFA! UFA!) Each federated republic would choose their own military spending and so on. Think of The Federation (United Federation of Planets) in Star Trek! That’s the type of idea I’m batting around here.

Click to enlarge the map!! In this vision of the future, South Carolina even secedes from the Southern Republic, because, hey, they've wanted to secede since birth.

I’m going even farther than “states’ rights.” I’m altering how the country operates–root and stem overhaul–by almost completely eliminating federal centralization as we know it. Why go this far? Because the paralysis of government has become so bad over the past 30 years that we have to consider crazy, radical ideas we would have shunned in disgust before.
Southern culture should never block Northeasterners’ ambitions for reform in New York where I live now, and visa versa. I moved to NY in large part to escape Alabama’s far-right public policy that was blocking my advancement, but while it’s better here, those policies (tax cuts causing huge deficits, social service cuts, the corporatist approach that keeps the institutional bias in Medicaid alive) FOLLOWED ME to New York because they’re federal policies too. And I believe the policies that affect me would be very different if only a Northeastern bloc could decide their own policies, vs. a national consensus accommodating Southern, Western, everyone’s views being forced on the Northeastern states. National compromises should no more be forced on the Northeastern states than on the Southern states (with some exceptions: states can’t disregard the certain parts of the current Constitution, like reinstating slavery or segregation).

This won’t happen any time soon (there is no public support for it) but maybe we’d all be better off if it did…

I just know that the only real solutions here are solutions as big as the problems. Without trying at least one of these big solutions, get ready to shout “HAIL CAESAR” and go full Banana Republic, while China becomes undisputed world hegemon.

Nick

Fix The Broken Foundation Before Building A Skyscraper On Top Of It

Posted by nickdupree – August 22, 2009

My biggest beef with Health Care Reform right now is that we’re building a new tower on top of a broken foundation. Medicare and Medicaid are badly broken, and we’re building more programs on top of that. Bad idea.

Insurance company bureaucracy is even worse, but federal programs have to be significantly better in the future for there to be meaningful competition. Right now, the government health care system is still far too fail. Medicaid is deeply corrupt, admitting people to nursing homes because institution owners and their lobbyists line the pockets of state legislators; people are even stripped of home care just for turning 21, and forced into institutions. As far as Medicare goes, its fee schedule encourages procedures over responsible diagnosis and management, causing the death of primary care and creating a costly and disastrous situation for patients. An old man will have no problem finding a cardiologist to do an angioplasty, but may find it near-impossible to find a primary care specialist who can manage him with meds instead.  A crude example, but it speaks to how costs can explode when so few primary care docs are around and it’s mostly proceduralists who have survived the extinction. Most new doctors the past few decades have stayed away from family practice because Medicare’s the AMA‘s drastic undervaluing of the E&M (evaluation and management) reimbursement codes make it difficult to survive financially as primary care physicians. You get what you pay for, and Medicare (and the private insurance industry that follows Medicare’s lead) pays for procedures, procedures, procedures, NOT talking to patients and thinking about what’s best for us. According to Medicare, taking a detailed history from a patient is worth nothing more than something like the first 27 seconds of a proctoscopy; I rarely see doctors taking detailed histories anymore, outside of residents in university hospitals who are ordered to do so. Do plenty of docs have to do more and more procedures just to stay afloat and keep their doors open? YES!!

Aside from a fee schedule that has buried primary care and incentivized unnecessary procedures, Medicare has also become such an unwieldy bureaucracy that even the most basic functions are drowning in red tape.

Read this personal experience from primary care specialist Dr. Toni Brayer:

Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.

But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.

May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.

I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.

I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.

I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.

I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.

Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.

A loyal American,
Internal Medicine (aka: primary care) physician

Source: EverythingHealth: Fix Medicare

It seems like the government doesn’t want doctors participating in Medicare, and makes the reimbursements so low and the hassles so high (they can’t even manage a simple change of address without a half-year bureaucratic nightmare) that more and more providers just give up. Yes, this is yet another case of the government’s unfortunate cranial-rectal inversion.

Dr. IcedLatte lists more aspects of modern medicine that desperately need to change here.

The Tower of Babel

The Tower of Babel

I support a public option in the new health care reform package, but (unlike some conservatives) I realize we already have several widely-used public options, Medicare and Medicaid, that the government runs, and should fix as a core part of health reform. If a new government program just continues the failures of Medicare and Medicaid, that’s not reform. We have to include the CCA in the bill, include a wider adoption of the PROMETHEUS bundled payment system (PROMETHEUS stands for Provider payment Reforms, Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understandability, Sustainability) so that the government’s skewed, guaranteed-to-fail fee for service billing system doesn’t bankrupt Medicare. Don’t build a tower of babel that’s just going to fall. Listen to all the experts, doctors and patient advocates, and FIX MEDICARE AND MEDICAID. I agree (mostly) with this article by David Ignatius, focus on health system reform, not just “health insurance.” We have to fix the foundation or the new skyscraper is going to collapse.

Nick

Ninth “Nick’s Crusade” Video Blog: Too Many Setbacks To Count

Posted by nickdupree – June 16, 2009

The Ninth “Nick’s Crusade” Video Blog

Too Many Setbacks To Count

Videographer: Alejandra Ospina
Writer/Director/Editor: Nick Dupree

Music by The Eagles

Footage of The Count from this YouTube video

Finished video made with Corel VideoStudio by Nick Dupree

Full transcript of the video, with links and footnotes:

This is Nick Dupree for the Nick’s Crusade Blog. I’ve now been in the institution for over 8 months now. I came here because there’s a lot more services, a lot more programs here, and a lot more flexibility and opportunities for people with disabilities. But the problem is, we’ve found that even though there are more programs here, bureaucracy makes it hard to get to them. We’ve had so many setbacks that it would take The Count to count them.

“I am The Count. Do you know why they call me the Count? Because I love to count things.” [maniacal laughter] [The Count counts]

First of all, the hospital is not familiar with discharging ventilator patients, because if you’re on a ventilator, this place is a lot like the Hotel California – you check in and you never leave…

“Mirrors on the ceiling,
The pink champagne on ice
She said ‘we are all just prisoners here, of our own device’
In the master’s chambers,
They gathered for the feast
The stab it with their steely knives,
But they just can’t kill the beast

Last thing I remember, I was
Running for the door
I had to find the passage back
To the place I was before
‘relax,’ said the night man,
We are programmed to receive.
You can checkout any time you like,
But you can never leave!”
[guitar solo]

So, because they’re not familiar with the discharge process, it’s been hard for them here at the hospital to get together the paperwork so I can get nursing and go home and have home nursing to support me at home. So what’s happened is, they do it wrong, the Dept. of Health in Albany sends it back and says, no do it again, and then they send it again, and then they say, “no, something’s missing, you need to train the caregiver and document it again, you need to send the documents from the home visit…” so we’ve experienced setback after setback, and it’s costing the government over $1000 a day, but that doesn’t seem to motivate them to expedite this. Hey, it’s not their money, it’s yours!

When people with disabilities are not as able to advocate for themselves or be persistent, they end up stuck for years and years and years unnecessarily institutionalized and watching the world and the people around them enjoying life while they’re stuck in an nursing home. So we’ve had setback after setback, and this week, after we finally got all the paperwork figured out, the nursing agency flaked out on us, so now we have to get another nursing agency. And it’s setback after setback, enough setbacks that The Count would love to count them.

[maniacal laughter] [The Count counts] [maniacal laughter]

Obama’s Blunder: Hiring Too Many Cooks

Posted by nickdupree – April 21, 2009

I like Barack Obama; I voted for him because I wanted a fresh start beyond the stale 1960s debates, Olbermann vs. O’Reilly daily “hot button issue” and endless socialism vs. capitalism rock ‘em-sock ‘em robots that lead us nowhere and accomplish nothing.  We can’t afford that crap in times like these.  And I wanted a serious overhaul of the health care system (Obama’s opponent pledged not to touch the employer-based health insurance concept that’s been hurting us for so long).

I don’t consider most of the right-wing criticism of Obama to be very valid, but I do have my list of beefs with Obama, like the lame inaction over Darfur, ignoring the previous administration’s illegal acts, denying due process to prisoners, and more.  I’m also deeply skeptical of Obama’s Afghanistan plan (as I discussed here).

But something else disturbs me that is rarely mentioned: the problem of too many cooks.  Obama is adding a “czar” for every occasion, and new offices for many of the czars.  It’s making an already overly complex and large bureaucracy even moreso, and leaving the system even more byzantine for successor governments.

byzantine

adjective

…

3.
highly complex or intricate and occasionally devious; “the Byzantine tax structure”; “Byzantine methods for holding on to his chairmanship”; “convoluted legal language”; “convoluted reasoning”; “the plot was too involved”; “a knotty problem”; “got his way by labyrinthine maneuvering”; “Oh, what a tangled web we weave”- Sir Walter Scott; “tortuous legal procedures”; “tortuous negotiations lasting for months”

From: byzantine – dictionary.com.

Ridiculous bureaucracy, of which I am an (all too familiar) opponent, is dubbed “byzantine” because of what happened to the Byzantine Empire, with its enormous and complicated legal codes only understood by a cadre of royal bureaucrats.  When the law is only understood by the few, that breeds corruption.  When government is too huge and complex to be easily accessed by the public, it, paradoxically, reduces government’s functioning and power.  The Byzantine Empire, actually a great milestone in cultural and administrative achievement, collapsed when it became too weakened by its own complexity and corruption to resist invaders (though there’s a lot more to it).

I don’t want the U.S. government to be “byzantine.”  Clinton tried fixing some of this with his “Reinventing Government” initiative (he usually gets no cred for this). They really did reduce some government forms from 30+ pages to 1 page, disbanded Reagan’s personal furniture maker and bought from Office Depot instead, and “cut the fat” from a lot of departments. They didn’t make much headway on consolidating and downsizing agencies like they wanted to, because of fierce resistance from bureaucrats prepared to defend their jobs Thermopylae-style, and they were occupied by other things (subpoenas for the White House xmas card list, etc.)  I would like to see “Reinventing Government” on steroids…radically streamlining federal agencies and attacking waste.  I want Obama to use an iron fist to override administrators defending their sacred bureaucratic turf, and radically consolidate our insanely duplicative, bloated bureaucracy. Dept. of Treasury and Dept. of Commerce should be one agency, for example. The Dept. of Homeland Security (Bush’s massive expansion of government) should be abolished and whatever is actually useful within it would be consolidated into the FBI and other existing agencies.

But streamlining is not the direction Obama’s going in.  Instead, we’ve got the newly created Office of Health Reform headed by Health czar Nancy-Ann DeParle, Urban affairs czar Adolfo Carrion Jr., Economics czar Paul A. Volcker, Regulatory czar Cass R. Sunstein, Climate Change czar Carol Browner, Border czar Alan Bersin, and more.  And, of course, a government performance czar (Jeffrey Zients) to help manage all the czar (“czar of czars!”)

Aside from the fact that a parade of “czars” in the White House may make the vehemently anti-monarchist Founding Fathers rise from their graves in a rage, triggering the much anticipated zombie apocalypse, there are serious concerns that “czars” greatly reduce transparency and consolidate power in the White House.

Zombie Jefferson will be the first to go on a rampage, devouring the brains of the innocent

Zombie Jefferson will be the first to go on a rampage, devouring the brains of the innocent

Cabinet officers are subject to Senate confirmation and oversight; czars are not.  Czars are hired directly by the president (“serve at the pleasure of the president,” always an odd, dirty-sounding phrase) and can refuse to provide documents or public testimony based on “executive privilege.”  Senator Robert Byrd raised his objections in a letter to Obama.  Czars “inhibit openness and transparency, and reduce accountability,” Byrd said.  “The rapid and easy accumulation of power by White House staff can threaten the constitutional system of checks and balances.”

My biggest concern is what this monster turns into 10-20 years down the line.

Known for their intellect and experience, these appointees could become rivals or advocates of competing ideas that could hinder White House operations if not skillfully coordinated.

Administration officials will have to “watch and see when it starts to become dysfunctional,” said Stephen Hess, a Brookings Institution scholar who has held several top government jobs going back to 1959. “It’s a very high risk because you’re adding without subtracting.”

When naming Volcker to his team, Obama could have scrapped either Romer’s or Summers’ agency, and divided the advisory duties between two groups, Hess said. “Instead, he adds a third.”

Paul Light, a specialist on government organization at New York University, said, “They’re kind of addicted to czars right now. I think they’re more trouble than they’re worth.”

Obama obviously disagrees. He has signaled plans to name Bronx politician Adolfo Carrion Jr. to a new White House post coordinating urban housing and education policies. And he has named Nancy Killefer to the new job of “chief performance officer,” which oversees many agencies.

He is hardly the first president to have a close aide coordinating several agencies. For years, a White House-based national security adviser has tried to put together information from the military, State Department and intelligence agencies.

But Obama’s creation of new policy czars and special envoys is pushing White House centralization to new levels.

Some government veterans say the strategy can help a president shape policy with minimum interference from Cabinet agencies. Under the right circumstances, a White House czar “can cut through some of the interagency disagreements that slow down and clog the policymaking process,” said Bill Galston, a University of Maryland professor and former Clinton White House aide.

But the system can be cumbersome, rife with jealousies and hampered by conflicting efforts and messages, Galston said. To make it work, he said, Obama “will have to be a way-above-average president,” which he has the “intellect and temperament” to be.

Source: AP: Obama’s White House: Big posts, overlapping tasks

Obama likely has above-average skills.  But what about his successors?  What will America become?

Nick

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