« Ruminations - 8mar13 (updated 11mar13) | Main | “Come, let us reason together …” »

10 March 2013



Been there, done that. The wife and I spent the last ten years keeping our elderly parents out of the hospital and convalescent homes. It's taxing on the health of the caregivers, unless you can afford extra help. As for saving money, one parent qualified for hospice care, which was a big help. A nurse would come to the house to check up twice a week, and another CNA would come by twice a week to help out with bathing duties. It was a shock though, when we found out hospice was billing Medicare $10,000 a month for these services.

Gerry Fedor

The one of the problems with this whole plan as America is not like Europe where (as when I was in Vienna) I saw a 90+ year old woman who was sweeping the street and cleaning her neighborhood.

Her family (who she lived with) was there for her, she was happy, she was working and contributing to her neighborhood and society, not like America where people like her are shipped off the nearest retirement home and their kids don't have room, or the means to give their family the life they deserve.

George Rebane

GerryF 1018am - Gerry, do you really think it's because "their kids don't have room, or the means to give their family the life they deserve", or is it that our culture does not teach/honor the multi-generational family living under one roof?

Steve Enos

George... you ask "is it that our culture does not teach/honor the multi-generational family living under one roof?". Of course the answer is Yes.

In the USA we tend to discard and warehouse our seniors and park them in "homes" until they pass on during the night. Sad stuff and the reality of this hits home when you experience it first hand with family or friends.

Regarding your above ideas about home care vs. hospitals. Real good ideas that would/could save money and have a number of other positive benefits. Problem is the current public and private health systems/insurance systems make this almost impossible.

They mostly won't support "in home" and family provided supported assistance and force the more costly hospital stay system. Mean time one must drain that persons resources to next to nothing in order to get help and care.

Like RL, I have been there and done that with family and friends. It's a system that needs real reform and the direction you point is a good direction for all involved and those paying the costs.

But hospitals now seem to be working to get folks out fast for the reasons you provided. Hospitals are not safe places to recover and getting out fast is now being pushed by hospitals for a number of reasons.

Had a friend get an open heart valve replacement, out two days after the surgery. Had a friend under go a triple heart bypass, out three days later.

I was with a friend through his triple bypass at the S.F. VA hospital. I was floored at the quality of the hospital and care at this VA center. It was outstanding on every level possible. I was greatly impressed and surprised at the ultra high level of everything I experienced and witnessed at the S.F. VA center and at the Reno VA too. But this is how it should be for those that have served our Country.

George Rebane

SteveE 1235pm - Good words Steve. And we might add that the 'doctor industry' is not much help either as it limits the levels of healthcare providers available in America, in addition to not allowing family members and other lay people to become certified in administering certain simple medical procedures and medications. The mystique of medicine must be promoted to the last penny.

Steve Enos

George, the senior issue "Big Wave" that is now starting to reach shore is Alzheimer’s and related dementia. This is a game changer to all our futures on many levels. The increasing human toll and financial costs will bury us.

Nothing like being an 86 y/o trying to care for your 85 y/o spouse, with little if any help. It's tragic. If you think cancer is evil folks, spend 15-20 years with a loved one with declining Alzheimer’s and/or dementia issues and toss in a side order of failing health issues for good measure.

My brothers and I experienced Alzheimer’s first hand for many, many years with my Mother. My Father fought a number of rounds with a deadly type of cancer and lost that battle. As ugly as cancer is, Alzheimer’s and dementia is a real contender for things most evil we should pray we didn’t meet up with on any level.

The sunset period of ones life should be lived out with dignity, choice and a say in the matter. The system of care and support we currently have on most levels strips dignity away.

George Rebane

SteveE 555pm - Good and poignant thoughts Steve. Our family has experienced the same, including Creuzfeldt-Jacobs (human mad cow disease). It is truly terrible, and more so because our culture has no established conventions for dealing with the end of life.

Teine Rebane Kenney

Our family has also experienced one child with a terminal brain tumor and another with Hodgkins Lymphoma. In both cases, home care was the BEST option. I agree, voting with my dollars would have been a bonus. To care for my sick children, I dropped out of the career paths of my contemporaries and chose to care for my children. Would have been wonderful to have been paid for that. And yes, over and over it was proven true: the best recovery post hospitalization happens AT HOME under skilled aide.

Paul Emery

Are you suggesting caregivers be reimbursed through the same funding systems that pay hospitals ? (medicare, insurance, etc)

If so let's revisit Riane Eisler and Caring Economics

http://www.riane Eisler.com/

George Rebane

PaulE 1021am - no, I didn't suggest that, but it is a good discussion point. In other words, if the govt wanted to make its healthcare transfer payments go further, should it reimburse at-home family caregivers in some manner, say, like vouchers for school choice? Bob's (earlcrabb) 921am opened my eyes to yet another aspect of Medicare's mismanagement, so it's worth a conversation. (My daughter, Teine Rebane Kenney 1055pm, most certainly could have used the money.) Should such transfers become part of a revised Obamacare, or a revised Medicare, or a new healthcare program, or ...?

Paul Emery

In my view that's a pretty important part of any such proposal. Relatively few families have a full time person available since it takes both partners working to pay the bills noways. Perhaps extending some kind of health emergency leave from employment may also be necessary. Without these elements it will only be available to a few. Sanitation is also a huge issue.

George Rebane

PaulE 1059am - all valid points. But you are suggesting an extension of public healthcare policy, could you put forth a specific proposal here in the spirit of 'Come, let us reason together'?

Paul Emery

I think it would have to be an extension of health care policy using the ideas you put forth here suggesting home care would better serve certain conditions than hospitalization. Obviously Medicare and insurance policy would be affected. I think you need to put the proposal together since it's your idea to begin with. I am suggesting you include my ideas in your proposal.

George Rebane

PaulE 1230pm - OK Paul, I’ll bite. I propose that the patient (or his legal agent) be given the choice of at-home, in-special care institution, or in-hospital recuperative care. That a voucher be issued to the patient that guarantees the payment of established in-hospital equivalent amounts for all equipment and services that is in the standard of care for such recuperations. These monies would be paid in the amounts incurred and directly to the vendors as approved by the patient or his agent. Additionally, the voucher would include one half of the non-physician care labor (nurses, nurses aids, physical therapists, etc) amount that would be paid to the patient directly, which amount can be used to compensate contracted care givers including family members. The monies would be disbursed at a nominal rate to match established expenditures (with applied for leeways as needed). The maximum duration of such payments would be set at the 80% duration of such recuperations (as determined from institutional records). If upon the determination of the attending physician the patient is not considered recovered at the 80% duration mark, then the patient’s care can revert to institutionalized care or an extension of in-home care as determined by the patient’s physician.

This policy’s measure of success would be a dollar-weighted reduction of post-operative morbidity and mortality rates as compared to established in-hospital statistics. The morbidity and mortality rate reductions would be equally weighted in the policy evaluation metric. The policy would be kept in effect at least as long as it is required to achieve a sample size that allows comparison of at-home care policy to in-hospital experienced rate to the 95% significance level.

Thoughts anyone?

Paul Emery

That's a pretty reasonable proposal George. Would you apply that to long term elder care? I know of a prime example I know of a family who chose to remove their parents from a medium care senior facility and take care of them at home. They had adequate retirement that became a salary for a grandchild who became a full time caregiver with spectacular results. Grandpaw passed away a couple of years ago (93) but Grandma is still doing well at 92. Her senility has been reversed and her eyesight somewhat restored. They eat high quality home cooked organic food with a special diet for their age and receive lots of love and 24 hour care. That's an ideal situation with available family, caregivers and housing that is supported by money that would otherwise go to convalescent institutions.


Nothing you can think of in health care is legal anymore.



George Rebane

PaulE 150pm - Good point Paul. Yes I would. Not only would it benefit the care receivers, but it would also help re-establish the multi-generational households that most of us still consider to be culturally valuable, especially in the influence/education it has on the youngest members in the household. They see the full cycle of life and learn of different times, ways, mores, ... .

Paul Emery

My family history in this matter is interesting. My Greek grandparents on my mothers side immigrated to this country before WWl. My grandfater came 5 years before my grandmother because there was no one left in his family to take care of his father (my Great Grandfather) She took care of him for 5 years and when he died came to this country with their daughter and joined my grandfather in San Francisco. They ended up living their dream which was to own their own farm (in Yolo County) Where they lived their life and raised five children.

It was part of their culture to take care of their parents in their old age and it would not have been tolerated to leave him with no care. Money was not an issue because they were pretty much self sufficient in those days.

My mother went back to Greece in 1988 and actually found her cousins and found out that the village Orthodox church once a year would have a day of prayers for relatives and the story of my Grandmother staying behind was still recalled in these prayers.

Kenya Hampton

I am a home health care giver and I have also worked in nursing homes. It is very hard to see families struggling with the costs of health care but there are many options out there. I think that home health is a great option for people. It can be less expensive than a nursing home and still lets your loved ones be in the comfort of their own home.

Michael Anderson

George asked:
"Should such transfers become part of a revised Obamacare, or a revised Medicare, or a new healthcare program, or ...?"

Of COURSE! Any and all of the above. Whatever works. But you can't kill Obamacare without a backup plan, ready to move into its place. And the only way that can happen IMHO is if you reform Obamacare instead of replace it. If the reforms are substantial, then perhaps it will eventually come to pass that this is a replacement. But I see no other way at this point other that to work within the Obamacare system to improve our national healthcare.

I am heartened to be reading the comments here. Very civil, with great ideas from all quarters.

George Rebane

MichaelA 832pm - I would still like to see a serious consideration of a post-Obamacare healthcare system that included 1) revision of tort laws promoting litigation, 2) expanding the levels of healthcare providers, 3) removing restrictions on where and to whom health insurance companies can sell products of their own design, and 4) revising the tax code that permits all manner of health savings accounts.


"But you can't kill Obamacare without a backup plan, ready to move into its place."

Yes, we can! Even Obamacare isn't ready to move into its place. It's losing steam and few are expecting it to work. A mess.

"Unaffordable Care Act" may be the legacy.

The Obamacare cheerleaders at Kaiser Permanente now show only 35% have a favorable opinion of the emperor's new health care system.

Ryan Mount

The backup plan all along has been single payer. My guess is that plan is waiting in the wings for its chance to enter the stage once PPACA implodes.

Never let a crisis go to waste. But never mind my tinfoil hat observation, take it from the horse's mouth:


George Rebane

RyanM 803am - Good link, that should go into everyone's 'Harbingers of the fundamental transformation of America' file. However, I do think your ability to reliably identify the correct end of the horse needs some work.

Paul Emery

Here's hoping single payer happens. Many of the polling negatives for Obamacare are from those of us that prefer single payer, one coverage for all.

George Rebane

PaulE 904am - I think it takes faith beyond measure to think that America's adoption of single payer will not be plagued with ALL the horrors of the EUs experience, starting with its immediate unsustainability and gitgo costs going astronomical. The only ones who will temporarily benefit will be those who don't pay taxes or have a pot to piss in. There has been no service run by the government that has not been an existential disaster. (Recall SS is not a service, but a check mailing operation.)

Paul Emery

Currently health care in this country is 18% of GDP. IF that isn't astronomical what is? It also must be noted that in yur view all the countries that have national health care are going broke which is quite an assumption.
There are far to many people suffering in our country from lack of health care to ignore this. Those who " who don't pay taxes or have a pot to piss in" are human beings who don't deserve to suffer because of their economic situation. Good health for all is a basic human need that I would put on a par with national security.

George Rebane

PaulE 1029am - Healthcare costs apparently have risen from 16% to 18% of GDP. Good enough, more reason not to relinquish such a huge part of our commonweal to the most inefficient institution within our borders.

I'm not sure what hills you are defending with your "people suffering" remarks. And I would put *nothing* on par with our ability to remain a sovereign nation-state in which we in liberty may create and spend wealth as we see fit.

Paul Emery

Well George, that's my view. If a country with the wealth and abundance we possess can't provide for the health and wellness of our people then it's a sad testament to us as a culture.

Ryan Mount

George Rebane | 02 May 2013 at 08:47 AM> However, I do think your ability to reliably identify the correct end of the horse needs some work.

I beg your pardon, but I don't understand that comment.


Are you suggesting there's some stash of money somewhere that can pay for this? In this "country with the wealth and abundance." I, and many others, would love to know where this money is. We have this federal and state debt that needs some attention as well. Schools with 36 kids/classroom. Everyone has their hand out.

I suspect that that "wealth and abundance" might equate to one less grocery store trip per month for my family. Perhaps one less Dental exam for the kids per year?* I don't know how much this is going to cost me and my family. No one will tell me. Can you tell me?

*Note: Dental insurance is one of the casualties of the socialized medicine. It's expensive. You can easily die from Dental infections. So the uninsured have just a few options:

1) Go to the ER. Get Antibiotics for infections due to a lack of care. Come back in a month after the infection returns and get another AB script.

2) Have teeth pulled, that is if they can even afford that.

3) Pay out of pocket (root canals, for example, cost anywhere from $1000 --> $2000+)

Paul Emery

We have enough money to spend 3 Trillion for our unconstitutional war in Iraq but not enough to provide health care for our families. The pharma-medical-legal-insurance industries spend a billion a year lobbying congress. Do you think that has anything to do with the state of affairs?

George Rebane

PaulE 611pm - IMHO, an additional $3T over the next ten years through Obamacare is not enough to provide anywhere near the level and breadth of services that today's 'dysfunctional healthcare system' provides. Free healthcare is really really expensive, especially when provided by an incompetent bureaucracy.

Paul Emery

I didn't say healthcare should be free. In Denmark, my favorite example, everybody pays taxes even if you're at minimum wage or collecting unemployment.

I'm not a defender of Obamacare so please unsubscribe me from requests to defend it.

George Rebane

PaulE 655pm - As soon as you give any credible evidence that you believe Obamacare is not right for the country and should be repealed, you will be exonerated from your past commitments to keep this atrocious law on the books. Until then and considering what leading Dems are now saying about that piece of pucky, you very definitely are about the best defender that Obamacare has left these days.


Ryan 8:03, Obama couldn't even get his gun control package through the current *Democratic* Senate. There's a slim chance in Hades that single payer could make it through the current Senate, and if Hades freezes over, the current House will be happy to kill it.

Obama and others made it clear in the beginning that they preferred single payer, and I wouldn't bet against them thinking the ACA would be the best path to it, but I don't think the country is going to buy that in 2014.

Paul, the military adventures in Iraq weren't unconstitutional, and we really couldn't afford them, the reason we put them all on the Chinese layaway plan.

Paul Emery


Please show me where I supported Obamacare in the past? Assumptions like this really bug me. I've always been a supporter of a single payer universal health care system. Here's California's version currently up for consideration.


Might I again add that the Repubs did nothing to reform healthcare during their tenure so why should we look to them for leadership?

George Rebane

PaulE 936am - While it is true that you promote single-payer nationalized healthcare and profess not to like Obamacare, you nevertheless have stated numerous times that Obamacare is the best/proper stepping stone to single-payer. This from these pages and our private conversations. I don't recall that you have ever proposed that Obamacare be repealed for the atrocity that it is.

As to your criterion that the Repubs disqualify themselves for reforming healthcare because they haven't done it in the past, I will see you the Dems also not having done it in the past, and raise you their doing Obamacare - the most expensive, poorly performing, economy destroying, misguided, perfidious, partisan, broadly rejected, ... healthcare legislation in this nation's history. And it was all passed by Dems only in the dark of night against the clearly stated legion of apprehensions (most of which appeared on these pages), all of which (and then some) have and are coming true. And you want those sumbiches to continue providing leadership in reforming healthcare??!! What is the definition of insane?

Paul Emery

Fair enough George. In your view what would we have in place if Obamacare were repealed tomorrow? My view is replace or reform Obamacare.

Paul Emery

That's reform or replace with single payer and reasonable tort reforms. Private insurance would still be available for those who can afford or prefer it, much like in most European systems.

George Rebane

PaulE 1010am et al - Yes, replace Obamacare. I have answered your question several times over the years since Obamacare raised its ugly head - most recently in my 118pm and 942pm in this very comment stream.

Paul Emery

The problem I have with your reforms are that they don't assure universal coverage for all. Can you explain how those reforms would assure that and if not what would the options be for the uninsured and their families?

George Rebane

PaulE 1123am - I will not solve your problem because my utility for healthcare does not require that government "assure universal coverage for all." Your tacit assumption that all healthcare approaches must meet that criterion is a facet of an (your?) ideology that not everyone shares. It all starts with a divergent understanding of what services we require the growing leviathan to provide. And this is a well-circled barn on these pages.

Paul Emery

Okay George let's approach this from a different more specific angle. My friend, who is a contractor ,has a wife is entering the last stages of cancer which she has been struggling with for years. They were unable to obtain insurance because of her condition after he became self employed. They were faced with the option of either selling their home and liquidating all their assets which would only pay for a fraction of full cancer treatment before applying for medicaid assistance or choosing alternative non medical treatments. In this case she went with the latter choosing not to drive her family into destitution for treatment that may not be successful. How would your vision of health care reform handle that situation?

George Rebane

PaulE 258pm - I think I recognize this barn. This again is policy making by the 'march of horrors' where citing a heart wrenching case is supposed to sway the nation into bankruptcy.

It sounds like the poor lady is in throes of terminal cancer and prepared to spend 90% of her life's healthcare costs now to at best marginally extend her life. And the looming correct answer you seek is that other people should foot the bill for that 90% for her and countless thousands of others who annually may suffer similar straits.

My 'healthcare system' is not nationalized, equalized, or 'fair' in any sense that you would accept. In my world such destitutions would be minimized and in the charge of charities that would allocate their resources according to their standards. To think that Obamacare would solve her problem in any kinder/gentler way is in my opinion utter lunacy.

Life is not fair, and guarantees health and happiness to neither the rich nor the poor. But the better off in wit and wallet will most likely also fare better in any situation. It is that existential inequality in those qualities that keeps us all working and studying and enterprising, which in the aggregate results in a better world for the most. But to promise everyone limitless funds for health, food, education, housing, ... is a soft-thinking socialist folly that portends ruin and tyranny.

Paul Emery

This "heart wrenching case" is real to my friends and millions of Americans live with the reality that any time they may be rendered destitute if illness or accident should break their stride. Then Social Darwinism it is George. Survival of the fittest. Compost the rest. In this case health insurance is not an option because to this family it is not available for sale at any price. I really don't the majority of Americans are with you on this George. Perhaps 20% at most and you'd better believe that most of them already have theirs.

"Social Darwinism is generally understood to use the concepts of struggle for existence and survival of the fittest to justify social policies which make no distinction between those able to support themselves and those unable to support themselves."

Paul Emery

In addition

I did not propose Obamacare would solve this problem. I am proposing that Single Payer Health Care properly managed would and it would not drive this country to ruin or tyranny.

George Rebane

PaulE 411pm - Well Paul, you put enough words into my mouth to choke a horse, but what else is new? But before we leave it there, I do want to communicate what appears to be a hot flash for you. My opinions and belief system are not the result of studying public preference polls, far from it. 40% of Americans have no idea what Obamacare is or that it is already law. And the public consensus you so honor goes down from there.

Socialist nationalization of production and services is an extremely complex issue that has been relatively easy to sell to the masses, depending on their level of dumbth. It always hearkens Jefferson's 'A nation ignorant and free, that never was and never shall be.'


Paul, what your friends with late stage cancer in the family want to buy isn't insurance, it's prepaid health care with an expected value over the next year up around $200K (my wild guess). They want to pay the same $8K (my wild guess) that everyone else in the risk pool are paying, and have the cost of their illness shared by all the others. Or just paid out of the goodness of the hearts at the insurance company and effectively shared by all their customers and investors (many if not most being retirement savings plans).

Buying insurance after it is known that one is gravely ill isn't available because it isn't insurance at that point, just as buying collision repair insurance isn't available after you wreck your car. What you're doing is paying the repair bill, or accepting that the wreck is beyond repair.

*IF* they were insured when the initial diagnosis was made, they should be able to continue to buy it at the standard rates. THAT is a regulation that is both market oriented (it encourages the well to buy insurance) and simple to administer. I've written that here before, and was heartened to see this in a conservative mag recently:

"As matters stand today, it is possible for families to stay continuously insured and yet, when moving from employer-provided insurance to the individual market, still face sky-high premiums because a child has a genetic condition or a spouse has battled cancer. That strikes most Americans as fundamentally unfair. Fixing this problem, however, does not require a full federal takeover of the health system. New regulations, recommended federally but implemented by the states, could give Americans new protections if they stay continuously insured. In practical terms, Americans should be able to move seamlessly between employer-based coverage and individually owned insurance without being subjected to high premiums based on the development of a costly health condition."

(no, I usually don't read Weekly Standard but found it googling for citations for another blog post recently)

Paul Emery


Why do you keep bringing up Obamacare? I wouldn't be polled as a supporter if asked.


That's a good reform idea for sure. It is a fact that many enterprising Americans do not pursue private business ventures because of the difficulty or impossibility of obtaining insurance.

The fact is they were insured at the time of diagnosis but couldn't buy insurance on the private market when the employment situation changed. So this is a "should" at this time not a mandate. Any ideas on this proposal George?

George Rebane

PaulE 946am - since you don't tag the comment(s) you are responding to, it's hard to have a conversation with you in a multi-threaded comment stream. I have used the referent 'Obamacare' in several senses here; one being as the label for Obama's ACA, and another as a nationally known and important component of public policy that is still unknown to the extremely ignorant and out of touch who comprise a major fraction of American adults.

Re Gregory's 801am referenced insurance transfer. That kind of transfer from employer-supplied to an individually owned policy with the same coverage would work only if the insurer remained the same and was able to put the covered individual into a risk equivalent pool of individually insured so that the adjusted premiums would somewhat track what the employer/employee paid.

We must recall that every insurance policy is a memorialized bet made between a specific insurer and insured at one point in time during which they each have a dollar compatible assessment of future risk. Their judgments are necessarily subjective and non-transferable between parties old and new, and from then to now.

The comments to this entry are closed.