When Stretching Isn’t Yoga

Stretch goals. Remember those? I hated them. They were impossible and rarely met. People felt set up for failure. They gave up. The organization did poorly and got crummy morale to boot. When I left corporate America, I thought I was done with those. Well, here we go again.

Welcome to Medicare for All, the ultimate health care reform stretch goal.

The Harvard Business Review, in an article called The Stretch Goal Paradox; confirmed the perils of putting forth impossible dreams unless you are already successful (that’s the paradox). Those who are in dire straits seem compelled to set out to accomplish the impossible, a Hail Mary pass if you will. But setting stretch goals, aiming for the impossible, is exactly what a group that is already at risk, shouldn't do. The criteria for success: a group with resources, people to support it, a recent history of success.

Oh, and the authors warn that it will be extremely difficult to achieve even in the best of circumstances.

So the question for the Democratic Party and its allies is: What kind of “company” are we right now? The one looking for a Hail Mary pass or the one well-positioned for success already? If we aren’t in a position to achieve a stretch goal, then being strategic with something that is a reach but not a moonshot, might be more likely to mobilize citizens beyond the base, and get something meaningful done on health care reform.

Just Put Down Your Fork! Obesity and the Health Care Debate

I like Bill Maher. I do. He supports PETA. He encourages vegetarian diets. He's rich. OK, so the last one is no reason to like him, but it's important to this post.

Recently on "Real Time", he got into a rant with Arianna Huffington about the role of personal responsibility in fueling health care costs. I'm sympathetic to the argument. It goes something like this: Obesity is creating an alarming rise in health care costs. Where there is obesity, there is diabetes, heart disease, kidney disease among others. We can lower health care costs by lowering our forks, giving up junk food, and using some old-fashioned will power to control our eating. The underlying premise is that obesity is primarily the result of overeating. As a health care practitioner, I like the simple elegance of that solution. A lot.

But there's more here than meets the eye. Really.

We're flooded with obesity statistics every day, usually accompanied by photos of fat people with their eyes conveniently covered by black bars. Or we get only their backsides. But if you want to see how large we're all getting, you don't need the media to tell you. Stroll through your workplace, the mall, your local grocery store. Look around at your fellow movie-goers. We are surrounded by fat people. What's worse, we don't even know who is fat any more. May I direct you to Match.com? Check out people's descriptions of their body type. Pay special attention to those who self-identify as "about average" or a "few extra pounds". Now look at the pictures. Often they are substantially overweight ("average") or morbidly obese ("a few extra pounds"). Uhhh, I thought average meant that they were not fat, not "toned", not "thin" ...just kinda in the middle, you know? Average. Then again, recall your stroll through your familiar haunts. What do most people look like? Yup. Big. Bigger than they used to be. Obesity is the new "average".

I'm biased. A "weight-ist", if you will. You probably are too, but won't own up to it. I absorbed a distaste for overweight people from my mother who had strong opinions about such things. I'm in my 60s. I remember when significantly overweight people stuck out in a crowd. The Conventional Wisdom of the time was that "those people" had no self-control. They were the poster children for the Deadly Sin of Gluttony. We felt little guilt for deriding them.

More than 50 years later, the belief still sticks: you're fat because you can't control yourself. Like every belief, this one is partly true. I overeat. Sometimes, I'm compelled ...like many people, I can slip into "emotional/stress eating". But is the secret to conquering obesity just exercising more willpower? Getting a grip? Perhaps, for some of us. But I don't think an epidemic emerged from a sudden inability to put down our forks. Especially among the poor, minorities, and the middle class.

Which leads me to three broader food-related issues that undermine our health and cost us money: 1) the poor quality of our food supply, 2) the near absence of people's ability to cook from scratch, and 3) the unavailability in most families (especially elderly and one-person families) of someone who has the time and/or energy to make a fresh, healthy meal. If we can't address these three, complex systemic issues we won't get very far trying to impose incentives for "healthy behavior" or for providing more efficient care to large numbers of people who have chronic conditions.

"Food, Inc.", a documentary on how our food is raised, concocted and engineered, is currently playing in our area. Go see it. It presents a visually compelling link between our consumption of food-like substances and the cost and quality of our health. I came to tears watching a lower middle class working Hispanic family shop for food. Two bottles of soda were cheaper that a bunch of broccoli. They had two children to fill up and with the cost of the father's medications, not enough money to buy the food that would avert further deterioration. One young daughter was perilously close to a diabetes diagnosis. The mother knew what she should be eating, but she couldn't afford it. They all worked 16 hour days, with no time or energy left for cooking at the end of the day. Three out of four of them were overweight or obese. This is not their fault. They want to do the right thing. The system conspires against them.

If you think this is a problem of poverty alone, you're wrong. While obesity declines as income and education climb, it remains higher than we can afford. And all those lovely kitchens in McMansions, are for show, not daily use. Those families eat out. A large proportion of adults my age are on multiple medications for high blood pressure, high cholesterol and depression (which is linked to poor cardiac health). Most of these illnesses are partially fueled by the hidden, unhealthy ingredients in food, the things we didn't eat 50+ years ago because they didn't exist. As an example, this week a study was released that revealed that the average American woman eats 22 teaspoons of sugar a day, almost all of it "hidden". Her healthy limit should be, at most, 6 teaspoons -- half that if she is sedentary. Flavored fat-free yogurt, a common health and weight loss food, contains the entire sugar budget for the day. Yogurt, for crying out loud.

So as you ponder your position on the health care reform debate, perhaps you need to challenge your biases. That's hard. For me, for you, for Bill Maher, who unlike most of us can afford to play the food game by "New Rules". But think about that Hispanic family, your co-workers, maybe your own family members ...and how difficult it is for all of them to buy, prepare or eat a high quality diet. Think about the cost of our heralded cheap food. Face the dirty secret that the decline in food costs almost directly mirrors the increase in health care costs. Then ask yourself who's to blame. Not so simple, is it?

Boomer and Busted

This is not fun. The whole lot of us, are going mad ... and feeling mad ....and soon, we'll be behaving badly. You just watch.

This week, MSNBC posted this story: "Boomers Face Stark Choices in a Bleak Economy". Now there's a headline that'll turn your blood to ice.

The article lays out the daunting tasks ahead for people my age who are too young and too financially vulnerable to retire. Between the crash in the housing market -- where most of us stashed a big chunk of our money -- and the crash in the stock market -- where our alleged retirement savings safely resided for "the long term" -- we've been left floundering. More dire, our jobs are at risk and when we lose them, many of us never find another. Today, even the poorly paying ones in retail and low-paying service businesses, are vanishing.

Losing your job when you are in your 50s and 60s is nothing like the experience when you are in your prime -- your 30s and 40s. Ageism rules, and don't for a minute think it doesn't. You are too expensive to hire -- not just the overt salary cost, but the cost of your health care may be higher. Your experience makes people reluctant to place you in a lower level job, where you might cause trouble for your (almost certainly younger) boss. You are presumed to be less adaptable intellectually, less technologically savvy, less interested in new approaches to work. And you are expected to tire easily and resist working long hours.

Most of this is bullshit. And if you've ever worked with a lot of 30- somethings, you should have some pretty eye-opening experience with the gap between the baby boomer work ethic and the one held by younger workers. But I digress. The bottom line: if we lose a job, we aren't going to find one any time soon and if we do, it will pay less.

The article goes on to promote a return to school. Go ahead, retrain, "re-invent" yourself. OK. I'm good with that. I've done that more than once. The last time, I spent the majority of my life savings going to graduate school in my late 50s. It landed me my current job, which I've just been told may be at-risk. For all the hype around the potential for growth in the health care industry, many hospitals and physician groups are down-sizing. They may need workers, but they don't have money to pay them. So what are we supposed to reinvent ourselves to do??

Yeah, I know, we are all going to have to work until we die. OK, I'm "in". But the assumption is that the work will be there. I fear that it won't. If my hunch is right, then what? The burden of this reality is not going to strike my generation alone. For those of us with adult children, the possibility is growing that we are going to have to move back to multi-generational homes. Parents, grandparents, and grandchildren may begin to live together again, and we will all be living with less. Even if the economy begins to recover over the next 12-18 months, our savings and our jobs will never return to the levels they were before the Great Recession of 2009. We are facing an entirely different future than the one we envisioned.

Compounding it all is our guilt and shame. We almost certainly made mistakes ...investing badly out of ignorance, assuming the boom times would persist, getting hooked by the seductions of a consumer society. Now, even if we still have a job, we know how thin the ice is beneath our feet. Most of us cannot survive a catastrophe -- major housing expenses, a dire health care diagnosis, a job loss. We have vowed to work harder, to prove our value to our employer, to be willing to do whatever it takes to earn a living. But the dice may not land as we hope ...and so much is out of our control. The article notes that we have become increasingly isolated, for we don't want to let on how scared and vulnerable we are. We are a proud and mostly optimistic generation, who believed we could achieve all our dreams if we just worked hard enough. Here we are. With dreams and assumptions shattered, along with our security.

On the community level, we need to use our legendary boomer creativity to imagine other futures, other ways to live and be of value. We need to consider the potential for founding new businesses that have growth potential. And we need to loudly and aggressively lobby for universal, government sponsored health care -- the source of our largest expense, a major deterrent to entrepreneurial activity, and a primary reason for bankruptcy.

On the personal level, we need to talk. To our kids, to our friends. We need to be honest about the reality that at some point, despite our best efforts, we may not be able to afford to live on our own, much as we dread that possibility. Some good may come of that. We may create stronger and more compassionate families. We have much to teach our children and grandchildren, if they choose to value our experience and wisdom. But none of this was in our plan. We never intended on becoming more dependent than our own parents were. But if we've hit our high mark, and it is likely many of us have, we'd all -- parents and children -- best be thinking pragmatically about Plan D.

The Professionals' Conscience

The President is about to piss off a whole lotta people, but I'm not one of them.

An anonymous source has leaked that President O is going to eliminate a rule that my nemesis GW issued right before he left office. The rule speaks to an issue that has infuriated me for a long time: the "right" of health care professionals to refuse to provide care that violates their conscience. Check out the arcane details of the proposed rule recision here.

What's with this "I can't fill a birth control pill RX because it violates my conscience" crap? OK, you're a pharmacist who is against birth control? Then don't become a pharmacist. Become a chemist instead. You a nurse who doesn't want to pull the plug on a vegetative patient? Don't work in an ICU, nursing home, subacute facility or hospice. Work in a pediatrician's office that doesn't face these ethical dilemmas.

Seriously, can you imagine a cop who had issues of conscience with arresting speeders? Or a science teacher who refused to teach zoology because it included sexual reproduction? Hey, if you oppose educating people on the biology of sex, become a damn math teacher.

It is absurd that people put themselves in professional situations that, by definition, require you to violate your beliefs, and then bitch because they have to do things they find reprehensible. Grow up. Pick another profession for crying out loud. I started out my nursing career in oncology. I repeatedly had to administer treatments to people that I thought were not being well-served by their physician, who were not being given sufficient information to make informed decisions. From my perspective, I was inducing unnecessary suffering. It made me nuts. You know what I did? I left oncology. I'm free to say whatever I please and I don't violate my fundamental principles.

All you "conscientious objectors", get over yourselves.

Hope Is In the Air

OK, the stats are out this morning and the economy is contracting like a sponge in Death Valley. Bad, bad stuff. Worst numbers in over 25 years. This is not a sign of hope. And yes, I'm scared to death when I think about the next 3-5 years. So, why a post about "hope" for crying out loud? Have I lost my marbles?

No, I'm thinking about President Obama's joint congressional speech. He was quick to point people to the other side of this calamity -- growing opportunities to change things. I'm big on change, especially radical or transformative changes. Rarely are those kinds of changes considered, let alone attempted, in stable times. The New Deal is a prime example.

Of course, those kinds of big changes can also have substantial negative impact, depending on who's at the helm. Prime examples are the radical policy changes of Reagan and Dubya. They utterly transformed our country -- eroding the Middle Class, nurturing the wealthy, fostering corporate greed, limiting people's access to the American Dream, despoiling the environment, compromising civil rights -- I could go on, but it gets too depressing and enraging. I'm not naive. Change can be a force for evil as well as good.

But there are signs that after this misery is over, transformative, progressive change will come. Here are some:

1- A story in this morning's New York Times describes the public's response to the cadre of Republican governors who are refusing to expand unemployment benefits because it would "hurt business". The stimulus money comes with some strings attached -- and those strings are designed to provide benefits to workers who, for technical reasons, are being denied state benefits. Guess who's pissed off? Might it be workers? People in deep Red states who are seeing just what those Republican governors really value? You know, the ones who fight for the lives of the "unborn" but who are more than happy to screw the living if it protects business interests. C'mon guys. Keep it up. That is the best way I know to turn your state Blue the next time around.

2- Yesterday's news was the release of the President's budget. Word is that the budget will attempt to rapidly dismantle programs reflecting President Reagan's cynical view of government and his me-first, screw-the-commons policy positions. Rachel Maddow listed very effectively last night (don't you just love her??), ways in which the new budget will support efforts to limit climate change, promote reform of health care and education, encourage energy and transportation innovation, place limits on gas and oil companies, bring reduced subsidies to large agribusinesses, and overhaul the tax code to bring more economic balance to society.

Visit msnbc.com for Breaking News, World News, and News about the Economy

You gotta give the Republicans credit: They consistently put their money where there values are. Well, it's our turn. President Obama is about to insert Democratic values into his budget process. Any and all of his proposed changes will significantly alter American life and policy for the next generation and perhaps beyond. Hey Gipper? You spinning in your grave yet?

3- None of the changes that Liberals want can come unless the ranks of Republicans holding power are thinned (see #1). So public outcry against the Neanderthal economic policies of Republican governors and Congressmen/women is essential. But we also need Democrats to stand up and push for Democratic programs that reflect what President Obama constantly calls "American Values". For most of our history, the call to live up to the better part of ourselves, was both American and Progressive. Those values are what made us Reagan's shining city on the hill ...not the policies he promoted. To that end, a group of activists, Accountability Now PAC, intends on targeting Congressional Democrats who don't support Progressive values with their votes. While this initiative runs the risk of generating counter-productive infighting and compromising the ability of Democrats to pass legislation in the near-term, it's about time that Democratic voters start to hold wishy-washy Democratic incumbents accountable.

As an unabashed Liberal, someone who believes that the foundation of the word "progressive" is progress, I'm hopeful. If we're smart and aggressive, real change might finally come. We are in for very tough times, no question. Many of my fellow citizens, including me and my family, are going to suffer in ways we hadn't anticipated and may not be prepared for. But if out of that suffering comes the change we need to ensure a better future for my grandchildren and children everywhere, then I'm prepared to sacrifice for the long haul.

That's why I will continue to look for hope amidst the rubble of our economy and communities. Our generation's legacy is on the line.

Health Care Policy for Dummies

OK, I'm trying to hold my temper, but I'm sitting here watching the Democratic debate, and I want to just smack Barack Obama. He and Hillary are debating health care. The contrast between the two is remarkable. She understands the business and the domain. He simply does not. He has a pollyanna view of health care that is consistent with his lack of experience on the national stage or in the trenches where the really big and powerful play hardball.

Let me cut to the chase: Barack's plan is right of center and far too Republican friendly. He is sacrificing principle and worse, he is violating basic business principles that make coverage work. He believes he's progressive on this issue. He's not. It is obvious he's never had to actually negotiate coverage. You cannot leave anyone out of the pool and make the thing work. It is a fundamental actuarial principle of the business. And whether Cigna or the Feds run it, you have to follow the same coverage principle. You must mandate coverage, just as Hillary and Edwards pushed for.

I have been an executive in an insurance company. I was intimately involved in managing care and helping to rate applicants. Barack says everyone who wants health care will buy it if it is affordable. Bullshit. I have seen many young adults -- working young adults -- refuse coverage because they'd rather spend their money on cars, electronics, entertainment. They do not believe they'll get sick. Wolfe Blitzer is right. Those people get sick and then the rest of us pay for it. Yes, people with little income for insurance...mostly responsible adults with families...can't afford the premiums. Subsidies are the answer, not exempting them from the system.

He also spouts that he will pay for his program by focusing on prevention. To paraphrase him: we'll pay for a dietician so we won't have to pay for a diabetic's foot amputation. Right. Has this man ever talked to someone who actually cares for patients? I do. I'm a nurse practitioner. I work with people who have heart problems and many of the illnesses that go with them, like diabetes. Even if you can get people to get control of their health and lifestyle (and let me tell you, this is a rare feat), this takes an enormous amount of time and MONEY. The payback is not in a premium year. Ever. He is totally nuts and clueless to think he's going to pay for his programs with this as a core strategy. It just won't work. And I think what distresses me the most is that this guy thinks he has answers when he is so clearly misinformed.

Hillary covers her program with new taxes and savings from negotiating pricing and instituting administrative cost savings. That may still not be enough, but it is much more realistic.

You know, I keep saying that I'll support Obama but the truth is, while he's charismatic, he just isn't a heavy hitter in the policy department. Worse, he has top advisors guiding him and they aren't pointing him in the right direction. Why would anyone think that would substantially change if he were elected?

I'm sorry, too much of this story feels like 2000, when the Republicans fell all over themselves lining up behind a guy who was charismatic and seemed like a whole new animal. He was an empty suit. I'm still not sure how full Mr. Obama's suit is either.

Lap Bands R Us

The Diabetic Quick Fix

Here it is. The lap band. The billboards advertising them, the TV ads, they never actually show you one. Cute little suckers, aren't they? You just pinch them around the stomach, fill them full of water to restrict the space you can dump food into, and you're good to go.

I'm a nurse practitioner. I have patients with them. Yup, they work. At least, for awhile. Diabetes improves. But in my experience, diet, nutrition, and lifestyle are unchanged. Same with other types of obesity/bariatric surgeries. I have patients who had gastric bypass 10 or more years ago, a more drastic approach to weight loss. Guess what. They are obese -- again. They are chronically ill. Some of them have even had a second procedure, to no avail.Without personal change, will improvements gained through surgery be sustainable? I have my doubts.

Typical of Western medical approaches, we do not address the underlying issues. Maybe we're sick because:

1- Our food supply is polluted and nutrient deficient
2- Our eating knowledge base -- how to cook, what and how much to eat -- is full of holes or empty
3- Our culture values quantity over quality -- in food, in housing, in income, in material goods -- which in turn leaves us fat, stressed, chronically time-crunched, in debt, and unhappy

As everything and everyone around us grows larger, as we feel less and less control over our lives and health, passive solutions like a lap band offer the ultimate cure. Good grief.

We're facing an election. Health care reform is on the top of the agenda. So a study like this that promises relief for millions of people, can provide a peek into what needs to be reformed. While this was an Australian study, American doctors and health care institutions (who stand to make a shitload of money off surgical solutions) are lining up to extol the virtues of this possible 'cure'.

If lap bands can be a solution to diabetes, then let's take a closer look at the study, OK? On the face of it, people who had surgery did much better than everyone else. Here's the glitch: the study compared a lap bad to 'usual care'. For you non-medical people, 'usual care' is the fucked up management you get in the current health care system. What you get when you go to the doctor and s/he tells you, "sorry, you have diabetes". Right this minute, in clinics and doctor's offices across America, "Usual Care" is handing you a pamphlet on diabetes (usually written by a drug company), a glucose meter for 'free' (provided by the folks who want your money for supplies), writing you one or more prescriptions, signing you up for an hour with a diabetic educator (maybe), and wishing you luck. In other words, 'Usual Care" is crappy care, plain and simple.

In the world of the lap band-aid, no one pays to teach people who have diabetes or who are at-risk, how to eat. No one shows you how to shop for and cook healthy food. No one works with individuals and families long-term to help them sustain changes or develop healthier eating habits. Obesity is a family problem, not just an individual one. It's also a food-chain problem, where we subsidize high-fructose corn syrup and processed foods at the expense of fruits, vegetables, and healthy grains. The recently passed farm bill did almost nothing to encourage the growth of locally grown, affordable organic vegetables or healthier school lunches. We're going to grow the same junk and rave about how lucky we are to have cheap food.

The cost of a lap band is at least $15,000; other obesity surgeries cost even more. Sometimes health insurance covers it. Sometimes not. When is the last time an individual or insurer invested this kind of money in a 2 yr program to reduce obesity, diabetes and heart disease? Short answer: never.

In the NBC video the lead researcher states that an adult cannot lose over 20 pounds and keep it off. Unless of course, a surgeon puts in a lap band (wanna bet he's a surgeon?). Bullshit. Granted, it is much, much harder for morbidly obese adults to lose weight and keep it off. But the study participants were overweight, not morbidly obese. We, as a country, have made no effort from a public health perspective, to look at the system that creates and nourishes obesity (no pun intended). That system includes schools, family farms, industrial agribusiness, processed food purveyors, the goddamned Food Pyramid ...I could go on, but you get the idea. This is a cultural, societal problem and while lap bands may be a stop-gap, and necessary for some, we're in a world of hurt if we don't invest in systemic solutions. At the least, we need to help families learn how to feed their kids to fend off the obesity epidemic. How 'bout that?

As for classifying a lap band as 'first line treatment for diabetes', God help us.