The Illustrated Man

Poster Boy
Image by slagheap via Flickr

Your necklace may break, the fau tree may burst, but my tattooing is indestructible. It is an everlasting gem that you will take into your grave. – Samoan tattoo artist’s song

It was a 75 degree January day.  To the east, across rigid mountains and the endless steppe of middle America, a third consecutive nor’easter was decorating New England roof tops with ice dams and eight foot icicles, while schools declared snow days and road crews could no longer find places to relocate frozen winter.

I was tempted to call home but it would only invite derision and accusations of abandonment.  It would be suicide to mention the 80-degree temperature difference or the grey whales in the distance spouting as they migrated down the Pacific Coast toward Baja California. I had paid the extra $8 per day to upgrade my business transportation from a dull Mid-sized sedan to a Mustang convertible.  The V8 engine rumbled underneath while the sun pumped precious Vitamin D into my skin.

It was Babylon revisited as I drove down an upscale Newport Beach boulevard reconnecting with my past life as a newlywed living in an 1100 square foot cottage less than two miles from the Pacific Ocean. As I soaked up my old neighborhood, I passed a new and unlikely establishment – – a tattoo parlor. Normally, one would be more likely to spy LA Ink between Chico’s Bail Bonds and a “We Cash Unemployment Checks” liquor store and gun shop.  This LA Ink was wedged between a Whole Foods and a Kinko’s in an upscale strip mall less than a six iron from Fashion Island.  I felt a sudden surge of abandon that was either brought on by the sun and nostalgia or a spike in blood pressure from the MSG laden Chinese lunch I had just devoured.  Gratefully, unlike the elephant crush of cardiac arrest, this feeling was clearly the soft anxious flutter of forbidden temptation.

As I idled at the red light, an attractive forty-something woman with a rose tattoo on her shoulder exited her Mercedes and entered the establishment. At that moment, I felt a sudden gust of wild hair desire to create a permanent symbol of my life – – a tattoo.

I had watched enough national geographic channel to understand the ancient and sacred Polynesian traditions of the tattoo. To Samoans and Maori people, the body “tatau” is an expression of profound significance and an indication of one’s tribal status, skill and ability.  It is a social birthmark that tells much about the person. On the other hand, I have also watched the TV show, “ Locked Up- San Quentin” where a tattoo might indicate how many people one has killed or a membership within a murderous secret society. It is a tricky thing to get a tattoo and a permanent decision not to be taken lightly.

Each ink emblem is a banner of self-expression and seeks to project to the outside world a physical expression of your intrinsic identity. In ancient times and tribal societies, the tattoo was a symbol of strength and order. It’s slow assimilation into western society came at the hands of adventurers and those seeking to distinguish themselves among a homogeneous society. The sacred nature of the tattoo became corrupted over time by Western culture. In the 1940’s, ink was found primarily on sailors or soldiers and was often etched in the image of a swim-suit model or a cartoon character.  In the 1950’s, delinquents and bikers adopted images of skulls and daggers and in denigrated society’s opinion of the tattoo as an art form.  The early 60’s witnessed an outbreak of hepatitis and blood poisoning that relegated the tattoo and its quirky artists to back alleys and disrepute.

My first memory of a tattoo was Popeye the Sailor Man.  The cranky but irrepressible cartoon mariner had two distinct blue anchors adorning each arm.  When fueled with cans of spinach, these inked images would literally spin and convulse on his arm – – leading up to extraordinary feats of strength.

Popeye was one of the few “good guys” that displayed tattoos.  In the 60’s, a kid was taught to be on alert if he spied an ink blot leaking out from underneath a white tee-shirt or tank top.  One was wary of a bicep that was protected by a dagger encircled by a serpent.  These marks meant membership in secret and illicit societies.  To be indelibly marked with a tattoo was a public admission to being a misanthrope, gang member, wayward merchant marine, non-commissioned officer or the survivor of a lost weekend while on leave in Subic Bay, Philippines. Many first time tattoos involved waking up in a flea-bag motel with a dry mouth, splitting headache and an empty wallet. Upon peeling back the dirty gauze from your shoulder, you discover the receipt for your bender in the form of a screaming eagle tattoo.

In the 60’s, women with body ink were associated with circus sideshows, Polynesian communities or the back seat of a Hell’s Angel Harley.  While rock icons and celebrity tattooist Lyle Tuttle opened the door for free spirits to express themselves with permanent badges of independence, conservative America was not ready to accept the ancient art. I can recall my rush to adult judgment when swimming at my friend’s house and witnessing his young uncle remove his shirt to show a Mako shark rising out of his lower back and twisting toward his right deltoid.  Having recently returned from Vietnam, he had changed and become more dangerous.  Clearly, the tattoo was a warning that I needed to avoid him – – lest he tried to get me addicted to drugs, and tattoo me just before we knocked off the local community bank. I will never forget that shark – it’s diabolical ebony eye focused on me, following my every move – wanting to drag me into the underworld of corrupt, soulless carnivores.

Later in high school, I became friendly with Bruce S, one of the many younger umpires who would call our high school baseball games.  Bruce had been a long-range reconnaissance patrol (LURP) soldier in Vietnam. He had seen a lifetime of carnage in just 14 months of combat.  He was a friendly but damaged soul that had died inside before the age of 25. His arms were adorned with dragons and American Flags.  He proudly displayed his “Semper Fidelis” Marine tattoo which promised: “Always Faithful”. He was haunted by nightmares and sometimes talked to himself, conversing with dead friends and imaginary foes.  His tattoos were badges of honor.  Bruce the LURP was Bradbury’s Illustrated Man trying to give a voice to stories too twisted and disturbing to articulate.  To understand his muscular mural was to understand a boy’s chronological descent into hell.

With Y2K, 60’s stigmas were shattered. Tattoos became in vogue and TV shows like Miami Ink celebrated the human body as a canvas for liberted expression. Generation Y was ready to declare rebellion against the established social order and wear it on their sleeves – literally.

As of 2011,tattoos are officially considered body art and fashion.  A best-selling fictional protagonist is now an anti-social, brilliant force of nature with a dragon tattoo. For girls, it seems the risk of stigma from a tattoo remains but it is more than offset by its perceived statement of personal power.   Yet, prejudices still exist in our society as new and old generations clash over the implications of body art.  Some still quietly judge tattoos as a sign of loose mores and vacuous minds. Yet, for the most,  tattoos are now viewed as less troubled and more tribal. In the end, it’s really all about self-expression.

I turned into the strip mall and sat in my car screwing up the courage to go inside.  I had always wanted a skeleton with a crown of roses chronicling my long, strange trip across forty years of following The Grateful Dead.  I might consider a celestial-looking compass underscoring my belief in God, my managing partner and captain. Yet I remained outside, debating between the imaginary risk of Hepatitis and a hip new tat.  It was exciting and scandalous – – a 49-year-old executive sneaking into a parlor to be branded like a Hereford cow.  Was it my declaration of independence or perhaps, simply a mid-life cry for help?

Perhaps the tattoo would force a unification of my myriad personalities.  After all, most of us lead fractured lives where we are three people: the person we project to the outside world, the person we secretly believe ourselves to be and the person our partner knows.  For many, the Holy Grail in life is simply to be the same person – – all the time.  To become one is to be centered. Perhaps a tattoo would force a shotgun marriage between my schizophrenic persona – blending the citizen, artist and the iconoclast. But what image could reconcile and combine these forces?

I sat in the parking lot watching the front door of LA Ink. A young, goateed man with a knit cap and dark glasses emerged with a long white bandage covering his forearm.  His tank top revealed a complex undergrowth of ink and imagery.

“Does it hurt”, I asked like a five-year old.  My face must have told my total story.

“Nah man, you should do it. Sort of feels like a burn or road rash for about a day.  It goes away.  Depends on where you get it.” He flashed a smile,  “Where the skin is thinnest, expect to grimace.” He disappeared between two parked cars.

I started to get cold feet.  Where in the hell would I put a Grateful Dead tattoo anyway? I’d have to hide it from my wife.  That would be tricky.  Perhaps I was not ready to make my life statement. I kept thinking about his warning, “where the skin is thinnest, expect to grimace.” I unconsciously rubbed the inside of my arm, turned the key in the ignition and drove to my next meeting.

I’m still thinking about it and probably will for a very long time. Perhaps if I finally ever do screw up the courage to get my ink, it will end up a traditional tattoo of a heart. It’s inscription will simply read, “Mama’s Boy”.

Jurassic Mom

Mother helping her young son to urinate.
Image via Wikipedia

All God’s children are not beautiful. Most of God’s children are, in fact, barely presentable. Fran Lebowitz

“He is in a phase”, she signed absent mindedly as she mixed ground beef, eggs and spinach into an any time of the day “feed a family” concoction she called “Joe’s Special”.  The phase was a term my mother used as an intellectual shield – an emotional whistling in the dark that reassured her and others that the highly anti-social behavior being exhibited by one of her sons was in fact, temporary.   “Phase, my ass. “ My father would hiss.  “I’ll phase him.” My father would always threaten to retaliate using whatever last word had rubbed him in the wrong fashion. If a child were to curse his brother calling him a “dwebe”, my father would snarl that if we did not stop fighting he would “dwebe” us.  He was, in fact, a paper tiger and his comments often actually made no sense.  His admonishment would only serve to confuse us as he mixed misunderstood teen epithets into a knee-jerk Molotov cocktail of threats.  My mother would sigh – trapped in this endless rut of testosterone and male thoughtlessness.  Life was not as she had expected.  She had come to understand that little boys really were made from snails and puppy-dog tails. 

She longed for a daughter but in a time before selective reduction and high-tech pregnancies, the risk of having a fifth boy was greater than her desire to enter a room perfumed with pigtails and Barbie dolls.  She instead dwelt in a land of dirty underwear, GI Joes, wet beds and savage tribal fighting.  Barely thirty with four boys was tantamount to a life of hard labor.  It was a physical world of daredevils whose sense of adventure was only eclipsed by a total disregard for personal safety.  Life was a succession of sudden earth quakes and flash floods that ripped across her domestic suburban life and hardened her into a clever cartographer who would come to master the bizarre topography of the adolescent mind. 

It was not atypical to have a child in crisis – a tiny mind struggling to adapt to the greater oceans of maturity.  On this particular day, my older brother was in the throes of some undiagnosed adolescent angst which manifested itself in a constant need to urinate. He could not actually pee with any person watching or standing within a twenty-foot radius.  This created a range of insurmountable issues for a family that lived in a four bedroom, two-bath home where the urinal was shared by four children.  While we gathered outside the locked bathroom door jumping with a full-bladdered frenetic wiggle, my brother would stand for minutes, a frozen Flomax poster child three decades before his time.  As we pounded on the door, he would swear at us and threaten to relieve himself on us.  We quickly realized his condition made this threat virtually impossible.

We tormented him mercilessly with nicknames like “pee-wee” and “peanut bladder”. We took advantage of any opportunity to distract him during a potty run. We were immediately chastised by my mother and informed that his condition was brought on by nerves.  It would only be a modest inconvenience.  This proved highly inaccurate for over the course of one weekend we waited a half hour at a restaurant, twenty minutes at a movie theatre and a grand 45 minutes outside of a gas station rest room while he concentrated – clearing his mind of any thought other than an empty night sky  and a great porcelain moon.  The slightest distraction was a setback – a knock on the door, a shout, a honking horn or the flush of a nearby urinal would return him to lock-down mode.  A week later, the doctor found nothing physical wrong with him and suggested that perhaps the frenetic rush of our testosterone filled home was overwhelming his nervous system.   “He’ll grow out of it”, the pediatrician reassured her. 

My mother improvised purchasing a knit ski cap and encouraged him to pull it down over his eyes each time he used the toilet.  “Imagine you are alone in the desert.  It’s night. No one can see you.”  He immediately questioned her. 

“What if there is a scorpion or a sidewinder?” Nearby, my father narrowed his eyes like a reptile as he peered above his Wall Street Journal.

“Listen, you numskull. There are no god damn reptiles or scorpions in Mom’s desert. “ 

My brother had a very high IQ and was not buying it.  “Which desert?  The Mojave?  The Sahara? There are Gila monsters, coral snakes…”

 “Enough! Why can’t he be on the moon for God’s sake?”

 My savant sibling rolled his eyes at my father’s obvious ignorance and asserted very empirically,” There is no gravity or oxygen in space.  It is 100 degrees below zero and my pee would freeze.”

 My father uttered a guttural growl and shifted from the room.  In time, my mother and brother agreed on a biofeedback loop that relaxed his bladder and allowed him to return to the land of the continent.  Her pragmatism was legendary with boys.  Yet, she longed for a girl to share secrets and dabs of perfume.  The secret society of boys was a dirty sock drawer of half-thoughts and grunts.  Yet, she would be denied entry to the world of girls and get drawn into a deeper season of young men.  She developed a keen antenna as sensitive as any mother in the animal kingdom.  She would innovate, investigate, interrogate and if necessary, incarcerate. She had to make adjustments for every conceivable circumstance.  “Life is what happens while your busy making plans.” She would quote John Lennon. When the unexpected came scratching at our door, she would accept life’s unannounced intrusions with a resigned sardonic greeting from Steinbeck, “Ah yes, the best laid plans of mice and men ….”

 Her life as a mother of young men was an anthem to family anthropology, tolerance and comical dysfunction.  A mother first learns acceptance and then comes to understand that it is perfectly normal not to be normal. It is the human condition to err and it is a mother’s job to ameliorate the suffering that accompanies accidents, mishaps and comical collisions. Now in her twilight years, she rests in a chair and remembers fondly the comical journey of her boys.

 She loves to retell the story of a certain January Saturday night. I still wince in pain at the stinging memory. She was readying for a rare evening out – a chance to disappear into the lace and tinkling cocktail glasses of an adult dinner party.  The teenaged baby sitter has just arrived.  My mother’s perfume permeated the upstairs hallway as she prepared for a long-awaited evening away from her feral boys. Her low-cut evening gown and pearl necklace were accentuated by crimson lip stick so red that it could knock a man into Sunday. 

 In the chaos of the adults changing to go out and the babysitter’s arrival, my brother and I shut our bedroom door, turned down the lights and began to play with his new Christmas present, a desk lamp with a high-powered light bulb.  We had discovered that if one turned the lamp upside down, it would project images on to the ceiling of the darkened room.  We laughed hysterically at the silhouettes of our hands as they produced dogs, rabbits and eventually more bizarre and inappropriate shadows.  This led to my brother putting his finger beside his shorts and making an even more obscene gesture.  More hysterical laughter followed. Another brother joined the exhibition.

 It was at this point, as is so often the case that a devil lighted on my brother’s shoulder. “Wouldn’t it be funny if we projected our private parts on to the ceiling?”  At 5 years old, I quickly agreed.  After all, we were boys and boys did gross things for a cheap laugh. Soon something that resembled the Hindenburg was floating across the white sky. The gigantic shadow was met with howls of laughter.  We quickly discerned that the closer the light was to the object being projected, the more pronounced the projection.  No one seemed too concerned that the bulb of the desk lamp was now heated to over 500 degrees.  As I volunteered to take another turn, my brother got a mischievous look in his eye.  To this day, he swears he did not intend to burn my “twig and berries” with the lamp. 

 My unearthly howl of pain seemed to rise out of the depths of Hades.  It was at this precise moment that my mother realized that a life with four boys would be a perpetual blind-folded rollercoaster ride.  If she could not have a little girl, perhaps, the best she could do was to make sure that the “little girl” inside of her survived this deviant siege from her feckless pirate progeny.

 Moments later, I ran out of the bedroom and down the stairs naked – shrieking that my franks and beans were on fire. The baby sitter was visibly unnerved by my nudity and hysteria. She was now having second thoughts about her evening assignment.  My father sensed this and immediately moved to reassure her as my mother tried to corral me as I contorted in naked pain. I distinctly recall her laughter and tears as she developed an ice pack fashioned out of my father’s underwear and a Saran Wrap. She smiled surveying the boy who literally and figuratively had been burned for bearing it all.

There would be decades of monumental blunders,  incidents and a lifetime full of pea-brained male mistakes.  Yet the girl became the woman, the nurse, the confessor, the educator, the ombudsman, the partner and the warden.  She grew up but never stopped softening our world, leaving in her wake a scent of love and understanding.  If you ask her today if she regrets not having a girl, she laughs. “Oh, I don’t think a girl would have survived in this prehistoric clan. There was only room for one girl and God clearly wanted that person –to be me.”

Be Careful What You Wish For America – The Debate Over Minimum Essential Benefits

President Barack Obama's signature on the heal...
President Barack Obama's signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)

The Affordable Care Act is officially under construction.  The framework for the minimum mandatory levels of benefits offered through state exchanges is now being researched and will soon be ready for prime time debate.

The Institute of Medicine, a non-partisan research group, has been retained by Health and Human Services to conduct public and private planning sessions to help shape final recommendations on what standard levels of benefits should be required as a “floor” for all health plans.

The queue of industry and special interest groups increases daily as stakeholders wade in to offer personal perspectives on why certain levels of benefits should be considered as “essential”. The stories will be heart wrenching as individuals plead for broader coverage terms and looser definitions of medical necessity to cover a range of therapies treating orphaned or difficult conditions that do not neatly fit into today’s definitions of coverage.  The unfortunate fact also remains that the average consumer expects “essential coverage” to be synonymous with open access, comprehensive coverage, minimal out-of-pocket cost sharing and an affordable price tag.  In effect, everyone wants a Cadillac when the nation can barely afford a Corolla.

As the IOM solicits perspectives from a range of medical, academic, public and private stakeholders, it is gaining valuable insights into the opportunities and land mines associated with attempting to define a basic level of benefits that can guarantee affordable, sustainable and high quality healthcare.  Those states that have already walked the path of attempting to define mandatory benefits are perhaps the best leading indicators of the intended and unintended consequences of setting benefits levels too high or at more minimal levels.  States such as Maryland, Massachusetts and Utah have struggled and led efforts to set up universal and affordable benefits anchored by standard benefits and medical necessity protocols.  In determining what should be covered by commercial insurance and Medicaid, these and other states can offer valuable lessons to legislators seeking to establish the boundaries of the coverage requirements under ACA.

As the IOM and subsequently HHS consider the flood of opinions from stakeholders, a few unenviable considerations loom large:

Essential benefits will dramatically impact the future level of benefits many employers choose to offer.  Essential benefit levels will determine whether employers continue to offer healthcare and/or what benefits are no longer subsidized. Many believe that if HHS establishes a “national” level of essential benefits, it will become the floor as well as the “mean” to which many employers will gravitate their current medical coverage levels.

A national essential benefit design that establishes lean levels of benefits will prompt some states to consider mandating levels of benefits above and beyond those required in a national essential benefits design. A national design that is too rich could accelerate the budget crisis in states as more employers drop coverage sending employees into exchanges and expanded Medicaid pools increasing the financial burdens already crushing state coffers.

States will naturally argue for the flexibility to administer their own versions of essential benefits, largely because of fear over escalating obligations under Medicaid, legacy coverage and provider issues, the recognition that healthcare is local and that there is no such thing as a “one size fits all” plan.  Legacy budget deficits, the unique nature of each state’s demographics and healthcare delivery systems (single hospital towns vs. large healthcare systems, urban vs. rural care ) and the political mood of its constituents will figure heavily in determining the appetite of each state to advocate a richer or leaner level of mandated essential benefits

While fiscal hawks fear an essential benefit plan that is too comprehensive and therefore too expensive, there is the potential that more pragmatic designs could prevail leading to an essential benefits plan that is less expensive and better designed than many current plans in the market.  Plans anchored by primary care based gatekeepers, value based plan designs, effective cost sharing to promote personal responsibility and consumerism, and network tiering to ensure plans only reimburse at the highest level those providers that practice efficient, high quality care – are likely to run at significantly lower medical trends and in doing so, be able to support lower premiums over a longer period of time.

Change Behavior or Ration Access – Nationalized, single payer health plans offer rich preventive and catastrophic care but suffer the reputation of rationed access issues when delivering elective or non-emergency care. In a political environment where there is often no will to change the underlying behaviors of those utilizing the healthcare system, the only way to control the costs that arise out of unlimited demand and finite resources is to ration access and reimbursement.

CMS may soon be dealing with similar issues if delayed Medicare cuts are ratified by the 112th Congress. Medicare and Medicaid recipients may find themselves with rich benefits but fewer providers willing to accept reduced levels of reimbursement as payment for services. If the provider does accept coverage, the coverage will undoubtedly carry longer waiting times. Providers will either limit the number of recipients they treat or continue down the path of the “triage” encounter as they attempt to make up in volume what they are losing in unit cost.

It is important to note that access does not equal quality.  Yet, many Americans currently believe access is synonymous to quality. In a two tiered public/private system, access is as much a privilege as it is a right. The single payer country determines the pace of one’s access based on medical necessity. The ability to pay for the right to opt into private alternative delivery is the only way of bypassing a payer’s medical necessity and access protocols. While many argue that today’s current for profit system already functions in this capacity, the majority of medical necessity issues arise out of insured individual and small business coverage issues where there is no purchasing leverage and scarce clinical data to support broader coverage.  Individuals working at larger, self insured organizations generally do not have these issues as employers act as plan fiduciaries and have the ability to make the final decisions on medical necessity and reimbursement.

Larger Employers Still Offer The Best Coverage and Most Balanced Cost Sharing – In the last ten years, employee out-of-pocket health cost sharing has risen 149% while wages have only risen 37%. According to a recent Towers Watson survey, the composite cost of healthcare per worker was $ 10,212 in 2010. The average cost sharing contribution per employee was $2,292. The average American worker makes $ 40,000 a year.  The total composite cost of health care per worker as a percentage of salary is 25%.  Employees currently share approximately 22% of coverage cost but only 5.5% of the total cost of this coverage as a percentage of their own gross earnings.

These numbers do not tell a complete story.  Cost sharing is greater among individuals working for smaller organizations as most small employers tend to subsidize less coverage and have less flexibility to affordably purchase more generous plans.  In addition, the average median wage for individuals working for employers of fewer than 50 employees lags those working for larger employers.  The crisis of affordability has been most acute among those who can least afford it.

At the same time as small employers are dropping coverage or fatiguing under its costs, as many as 75% of employees in a recent PWC survey, said that they would prefer to be paid salary in lieu of benefits – opting to purchase healthcare as individuals through newly established exchanges.  It is interesting to note in this PWC study that many of these same employees grossly overestimated what they believed their coverage was worth in additional salary. The question remains for many employers and for those watching healthcare reform develop – can affordable and sustainable essential benefits be established that can incent smaller employers to maintain and even potentially, rejoin those offering coverage?

As many as 70% of Americans earn less than 400% of the Federal Poverty level – the current cut off for ACA offering pro rata subsidies to purchase healthcare through exchanges. If essential benefits begin to eclipse those benefits currently offered by employers and subsidies net a savings to consumers, we may witness a larger migration of employees and their employers out of employer sponsored plans. It then falls to the Congressional Budget Office to recalculate whether the larger base of exchange participants and subsidy recipients has turned a modeled $ 140B reduction in public spending into a massive drag on the national deficit.

A more basic level of affordable essential benefits could induce employers back into the market as well as usher in a return to defined contribution style cafeteria plans – An essential benefits plan anchored by 100% coverage for primary care, shared responsibility through a health savings account, tiered networks, centers of excellence for chronic care, primary care delivered through medical homes and/or gatekeepers and compliance incentives could achieve cost savings while offering coverage  greater than bare-boned mini-med coverage.

A lower level of mandated essential benefits could also prompt employers to reduce richer coverage to a new, more affordable common denominator.   In aligning their benefit plans to a national norm, employers could adopt a defined contribution benefits approach – choosing to fund up to the level of benefits required by law and then grossing up individuals’ salaries one time to afford them the opportunity to spend dollars as they see fit e.g. greater take home pay, purchasing of voluntary benefits, upgrading to more generous medical designs etc.

Better Coverage Does Not Translate To Better Health – Coverage and consumer advocates will be pushing for expansion of coverage definitions to include diseases and medical conditions that have historically been excluded from private insurance.  The definition of medical necessity will be debated as advocates argue that comprehensive coverage will translate into improved public health. One has only to look at financially distressed municipal and collectively bargained plans that offer rich, first dollar coverage combined with broad open access networks to see that better coverage does not translate to better health.

To define and mandate essential coverage is to walk a mine field of ethical, moral and social issues. Some therapies may not necessarily improve the status of one’s health condition but may prevent it from becoming worse.  The unenviable task of establishing a process for determining medical necessity is the first step toward the difficult process adopted by other countries who have wrestled with the cost/benefit of determining what gets covered and what does not.

The UK’s National Institute of Clinical Excellence which determines medical necessity and establishes the basis for reimbursement of certain therapies is often maligned for the difficult choices it makes regarding palliative care and determinations surrounding when and how it may pay for experimental therapies. This is the unenviable role of any payer. Whether it is government making the call or a for profit insurer, any thing that falls to the unreimbursed side of the ledger will be viewed as a diminishing coverage and ultimately public health.

Now is a time for austerity – The dangers of creating unsustainably rich benefits plans are real. Not unlike Medicare, a rich essential benefit plan that drives higher medical trends will contribute to rather than reduce the public debt. If employers choose to drop coverage and more consumers receive federally subsidized coverage, the market will reach a tipping point where federal expenditures for healthcare outstrip the government’s ability to pay.

Aside from raising taxes and increasing assessments for failure to cover employees, the government will want to pressure the provider side of the market to reduce the costs of its services.  If the private insurer market can not reign in the costs of a rich essential benefit design (and they will not), there is a strong possibility that there will be a renewed call for a public option.  Once enough individuals join a cheaper, taxpayer subsidized public option, the public option payer will begin to ration reimbursement to providers as CMS has done with Medicare.  While single payer advocates argue that doctors and hospitals would have no choice but to accept reduced single payer reimbursement, most industry professionals argue that price controls as a means of controlling costs will lead to diminished quality and reduced investment in innovation. This is happening today under Medicare and Medicaid.

The table is being set for another food fight around health reform.  As healthcare impacts every American, we can expect 300 mm opinions on what “essential benefits” should cover.  It is a critical argument at a historic time for our country.  Without introducing fiscal restraint and evidence based medicine into this debate over essential benefits, we may end up with a rich and totally unsustainable level of healthcare.  As a nation we are already suffering from the palpitations of fiscal heart disease and the obesity of public debt. Offering too generous essential benefits could very well induce a budget coronary from which it will be hard to recover.

Be careful what you wish for, America. You may get it.

Michael Turpin is Executive Vice President and National Practice Leader of Healthcare and Employee Benefits for USI Insurance Services. USI provides a range of business and risk brokerage, consulting and administration services to mid-sized and emerging growth companies across the US. USI is privately held and is a portflio company of Goldman Sachs Capital Partners.  Turpin can be reached at Michael.Turpin@usi.biz

Wake Me When It’s Over

hibernating

“Every winter,

When the great sun has turned his face away,

The earth goes down into a vale of grief,

And fasts, and weeps, and shrouds herself in sables,

Leaving her wedding-garlands to decay –

Then leaps in spring to his returning kisses”

–   Charles Kingsley

This first month of the Gregorian calendar is a time for reflection, self-flagellation and cynicism. It is the nadir of the solar year and the emotional equivalent of the basement level in the underground parking lot of life. January is named after a feckless Roman God named Janus – the God of all passages. Literally translated, he is the God of Doors and Gates. We essentially named the first month of the year after a guy who stands with a clipboard and velvet rope deciding which of us gets to go through into the new year. As jobs go on Mt Olympus, being an immortal doorman was not the best assignment.  You could be responsible for oceans like Poseiden or the underworld like Hades – where there were very good parties and no supervision. Personally, I admire the lesser known Gods like Lecheros who was the God of Greek fitness instructors.

Yet, I identify with Janus. I imagine him as class clown – overweight and acerbic sitting at the back of Zeus’ lectures as he wisecracked under his voice and passed notes to Aphrodite in hopes that she might go out on a date with him.  There were no mirrors in Janus’ house and he filled his garden with laughing hyenas.  He thought he was funny.  Perhaps after a tenth consecutive rejection from Aphrodite who was dating Apollo because he had biceps and a fast car, Janus snapped and made a flip remark about Zeus looking a little “prosperous” in his tunic.  “Has our divine father violated the laws of moderation or perhaps he has mistakenly sat on the empire of Gaul by mistake?“

The next thing he knows, Janus is passing out hand towels in the Mount Olympus executive bathroom.  After a millennia of squeezing soap into the hands of lesser Titans, Janus is finally promoted and immortalized as the Father of January responsible for the first 31 days of the year. In the Northern hemisphere, this assignment is clearly a punishment.  South of the equator, it is a pretty good gig especially January 1st in Rio.

A northern longitude January is not a time to be a mammal. As warm-blooded, propagating, card-carrying primates, we were designed to be dormant creatures in winter. It is our genetic predisposition to gorge on fatty, high carbohydrate foods, eat take out, and then root around for warm, dark places to hibernate. Some mammals choose to hibernate symbolically eschewing social engagements and hiding out under generous oversized winter clothing. Others retreat into mahogany cocoons of work.

It is a fact that our brain chemistry changes with the lack of winter light.  We become irritable and restless.  Sleep eludes us.  Our dopamine and serotonin receptors begin to flicker.  Our brains become a rolling brown out of highs and lows as we grow desperate for a 12 hour day of sun and the green grass of spring.

The first month of the year can be an endless squall line of Alberta clipper storm systems surging down from the Great Lakes that pull in moisture from the South – producing snow and myriad reasons to be lethargic.  Lethargy and self-pity are two overly maligned character defects that can turn even the most selfless among us turn into an effective whiner and complainer.  Janus intended that his month should have this effect on us. If he had to guard all doors and public bathrooms, no one was going to be very happy in his month.

He decided January would be a time for remorse, resolutions and a mounting physical and emotional pressure to change – preferably into a Greek God of War with a pimped out V12 car. It would be up to us as mere mortals to float above our weaknesses, fueled by the hot air and methane of good intentions, poor digestion and self-loathing.

A few brave souls seek to defy the laws of hibernation and embrace January.  They firmly rest their hands on their hips, throw their heads back and offer the God Janus their most indignant pirate laugh.  These mockers of the Janus own an entire super hero wardrobe of spandex, Gortex, okaytex, Underarmour, and polypro clothing.  They have snow shoes, ice axes, crampons, cross-country skis, snow skis, ice fishing shacks, snow sleds, snow mobiles and snow saws for building igloos. These hardy souls secretly want to hit a patch of black ice, skid into a ditch and use all their survival training until they are rescued and offered an opportunity to be featured on “I Shouldn’t Be Alive”. These winter-lovers are perpetually happy.   While you are scrawling “I hate winter” on the frosted mirror of your bathroom that never heats up, these psychotic winter sprites are outdoors shoveling snow or preparing for a Polar Bear plunge in Long Island Sound.

The Saxons referred to January as “Wulf-monath”, the month of the wolf.  Others considered it “the time of ice”.  The month has a bad track record in history.  Instead of just laying low, mortals feel the need to betray their natural instincts and crawl out of hibernation.  The need to get a head start on the Gregorian calendar has caused many well-intentioned world leaders to move across a denuded landscape of poor choices to attempt to influence the trajectory of a new year.

In 1644, Brit Guy Fawkes was convicted of attempting to blow up Parliament. It seems dissatisfaction with a two-party system and government waste traces its roots well beyond the 112th Congress. Fast forward to January, 1862, when the first income tax was proposed of 3% on incomes above $ 600 increasing up to 5% for incomes up to $ 10,000. I mean, really.  As if fighting the Civil War was not enough, the average American had to file their first income tax return.    In 1874, New York City annexed the Bronx.  Enough said. In 1899, the US liberated Cuba from Spain, presumably to gain access to some better public beaches.  However, they failed to outlaw bearded people wearing berets on the boardwalk which was our undoing.

Leaping ahead to 1945, January was the month where France was admitted to the United Nations to offset the heartburn of growing American hegemony.  France actually nominated Russia the following month but could not convince people that if allowed to join the UN the Russians would bathe more and only invade countries with names that ended in a vowel.

In 1946, Japanese Emperor Hirohito announced he was not a God.  He was actually a pauper named Ichiro Kawasaki who had agreed to switch places with the real Emperor who was determined to abdicate his royal role to open a sushi bar in Soho.

In 1950, Ho Chi Minh began a campaign to rid the French from Indochina. Earlier in the month, President Eisenhower, suffering from a prostate infection, is misunderstood during a meeting with the coalition French President, Georges Bidault. As Bidault presses Eisenhower to renege on our commitments to Ho Chi Minh (who fought side by side with us against the Japanese) and support reintroducing French colonialism back into Vietnam, Eisenhower confides to an aide that he must go “wee”.  Bidualt is overcome with gratitude assuming the American president has just consented, saying “oui”. The rest as they say is history.

In 1959, Fidel Castro leads Cuban revolutionaries to victory over Fulgencio Batista and closes all public beaches and mafia owned casinos.  The Kennedy family fumes over unreimbursed hotel deposits and vows revenge. In 1978, The Sex Pistols performed their last concert at Winterland in San Francisco.  History as we know it, essentially ended on that January when nihilistic Sid Vicious hung up his angry guitar. A year later he was dead of an overdose.

January has its high points with the Rose Parade in Pasadena ( isn’t California in the Southern hemisphere?) We do have football playoffs, the return of the pro bowling tour and the reconvening of Congress. In between bouts of the flu and a false positive in the stock market known as the “January Effect”, mankind looks ahead to Fortunate February – a month that arrives faithfully with perfumed promises of Valentines and better days ahead.

Personally, I think we should be allowed to sleep through the entire month of January. The Northern hemisphere world be better off and we would really save on our electricity bills.  Why not just deploy the old Vonnegut “night canopies”, hibernate and wait until longer days restore our sanity and replenish the chemicals that fire our neurotransmitters. A little dopamine and a little less dopiness could make all the difference in a flat, crowded and discombobulated world.

That’s it. Hold my calls. I’m going to go lie down.

Living With The Lost Boys

Cover of
Cover of The Lost Boys

The sudden pivot in the meteorologist’s forecast was highly displeasing. Having already missed an opportunity for a white Christmas, I was now fixated on our imminent four day mini-break to Orlando where we would achieve some old fashioned family time with our increasingly oversubscribed teenagers.

Boxing Day was spent sluggishly cleaning up from Christmas and nervously watching the weather channel as the predictions of a winter nor’easter were confirmed.  A perfect storm of airline emasculating, zero visibility winds and tarmac snarling snow had descended over the entire region. With snowfalls predicted to entomb the tri-state with levels of up to three feet, I started to understand why native Northeasterners have come to loathe the romantic notion of a late December snowstorm. The woods may be lovely, dark and deep but snow means no flight out to find some heat.

Our flight had an ETD of 6am Monday — during the peak of the storm. The question was not whether our flight would be delayed,  it was simply whether we would be able to book a later flight once the airline came clean and cancelled our morning escape to Florida.

At 11am Sunday morning, Flight 987 was officially cancelled. The 800 number provided by the airline was overwhelmed to a point where any ticket holder tenacious enough to cling to the queue was being asked to call back later – and then uncerimoniously dropped from the call. Logistical certainty was in short supply on this day. We continued to badger the airline to determine if a late Monday or early Tuesday departure might salvage our best laid plans.

After finessing our way to a customer service operator ( I do not recall how we found this trap door – perhaps we indicated that we had “ special” needs ), we were told that we could get five tickets to Orlando late Wednesday evening or early Thursday morning. The understanding agent did not seem to divine that this new itinerary would afford us less than 48 hours in the Sunshine State.  Given that 30 of those hours would be either dark or with temperatures less than 50 degrees, I was skeptical of a decent return on investment.

The agent offered to reschedule our return but this would require rebooking my tickets for an additional $150 penalty per ticket.  I did some quick napkin calculus and determined this vacation would cost us around $100 for each hour of potential sunshine. I could save $3500 if I bought everyone their own jar of Vitamin D and three free sessions at Savage Tropic tanning salon.

We peacefully euthanized our vacation late Boxing Day afternoon. Our teens temporarily mourned the passing of our trip the way one might lament the death of a distant relative. After five minutes of self-reflection, they shifted their attention to the living and began rapidly pinging their friends for sleepovers, parties and any other forms of nocturnal activity.

My wife would require more time to recover from our vacation’s sudden cardiac arrest.  She was facing the grim reality of an entire week with a thoughtless quartet of the undead – creatures of the night who would conspire to overrun her best efforts to keep a clean house, avoid endless meal preparation and hourly carpools.

As a stay at home vacation Dad, I am at best,  a weak surrogate and at my worst, a human sinkhole of mixed messages undermining my family’s carefully negotiated routines and boundaries regarding curfews, chores and accountability. I am like wildlife in the garden – a novelty that is glimpsed at dawn and at twilight but rarely during day. It seems only mad dogs, Englishman and the unemployd venture into the noonday sun.

Instead of pushing everyone to bed at an early hour for a December 27th 5am departure, we stayed up until 2am playing poker and watching old movies. Our cancelled flight allowed us to dive into a week of freshly fallen snow and a clear calendar.  I quickly took the cue from my teenagers and began a slow transformation into a vampire.

My first mistake was suggesting the XBox 360 be moved upstairs from the basement into the family room so we could enjoy a big screen version of FIFA 2011 soccer, NCAA football, Tony Hawk Underground and of course, the culturally enriching Call of Duty – Black Ops.

Most of my “black ops” activities are confined to eating unhealthy food late at night and frivolous purchases on eBay. However, I was now being recruited into an adolescent band of brothers whose motto was “leave no man behind – alive.” Aside from their annoying habit of shooting me in the back for sport,  my boys drew me into hours of  constant violence in some of the poorest nations around the globe. Other than learning how to operate an automatic Famas gun, throw a ballistic knife and engage cross-bow explosives, I was beginning to show signs of PTSD and was not improving domestic policy at home.

Later that evening, my wife realized the open week was not trending in her favor. As she laid down the holiday rules and regulations ( she had just discovered that the dog had urinated by the door because none of us had noticed his whimpering ),  I stood by her side with genuine disdain for my teens. “Look guys, mom is right. You need to pull your weight around here.” She turned and looked at me incredulously. “Really?”

Falling in with these slacker vampires had been so easy. It was reminiscent of college — late nights,  sleeping in until noon, occasionally venturing out to a movie, ordering take out, and groaning with exaggerated inconvenience when asked to do anything where there was nothing in it for me. It was an amazingly rapid metamorphosis from parent to parasite.

Two days into my Twilight regression, I had my moment of clarity.  I glanced up to survey a hoarder’s landscape of squalor – – Cheez-It and Goldfish boxes, empty bottles of diet coke and empty Nutri-Grain wrappers. The evening before, I had stayed up until 3am to finally defeat my eldest son in a barn burner football game that went into double overtime.  The dog was asleep on the couch while two teens sat in a digital stupor on separate computers watching reruns of Modern Family on Hulu. To the shock of my fellow primates, I pushed the “save” button on my latest game of NCAA Football.  I was now into my third season of the Dynasty segment of NCAA Football 2011.  I was no longer a contributing member of society but I was virtual head coach of the USC Trojans. I had also developed an almost stenographer type dexterity with my fingers – using what felt like 12 digits to work every A – Z button on the controller.

My son glanced up, “Dad, where are you going? You just unlocked a new level in your game” A new level?, I thought.  I was suddenly very afraid that if I descended deeper into this artificial gridiron matrix, I might never return.  I had to escape from the underworld of the undead and return to the surface of the living – and I had to leave right now.

I showered and shaved, glancing at the unimpressive image of a pale, blood shot-eyed baby boomer. I emerged into the crisp air and sunshine of a gorgeous winter afternoon.  I had to get away from my home and drive – – anywhere.  My car seemed to guide me into town where the sidewalks were likely to be alive with adults and responsible people – presumably others who had missed their flights or did not live in a sarcophagus of teens.

Suddenly, I spied my wife’s car and spotted her moving slowly down the street – presumably window shopping for post holiday bargains or a family practice attorney. “Hey” I said breathlessly as I caught up to her. She was pleased to see that I had escaped the iron grip of the Lost Boys.   We lingered over a latte fueled lunch and made plans for the new year.

The afternoon was dying and yielding to purple twilight. Suddenly, the streets were beginning to empty. The human beings were slowly returning home to prepare meals, read books, rest by a fire and contemplate the next days and all of its possibilities. A knot of new shadows appeared outside our café window. Six young vampires wearing cotton hooded sweat shirts, shorts and high top sneakers were moving across a frigid street on a restless roll. Two boys yelled into the cell phone of a third as he held his phone back and shoved the nearest vampire. They had all temporarily abandoned their computers and XBoxes to roam the town in search of a source of entertainment.

I felt a Call of The Wild stir as I surveyed the aimless, rudderless spill of hormones as they splashed on to the sidewalk. They would soon end up at a new safe house, retreating by the light of day, waiting for another restless night. My blackberry suddenly buzzed and a message appeared from the world of adults – – a misguided colleague choosing to work the graveyard slot between Christmas and New Years. I put away the blackberry and returned to my partner and to our  plans.

I smiled realizing that I did not make a very good vampire. Vampires did not understand the difference between living in the moment and living as if there was no tomorrow.  Vampire’s consider the past an empty bucket of ashes, the present an endless horizon line road and the future as something that happens to other people.

My wife and I were thinking about the future, about our new year and about things we needed to do to make a difference. I felt my chin, freshly cleared of a 48 hour goatee of vampire stubble. They had almost pulled me in – into their red pill world of artificial intelligence and the insatiable craving for constant distraction.

I had survived my time with the Lost Boys. As I sipped my coffee, I wondered how it was possible that I had ever survived the purgatory of my own youth. For all of its challenges and responsibilities, it was good to be above ground and among the mortals ready to take on another new year.