thinkfeel's Open Salon Blog

Health reform - big elephants in the room

Fri, 23 Oct 2009 15:10:10 -0400

With the health reform debate being front and center for the last few months, as a culture, we have pretty much settled on the meme that the insurance companies are the villains. Another meme is that the villains are American consumers and agribusiness because they are complicit in the creation of unhealthy lifestyles.

While I don't necessarily disagree with these arguments, I am concerned that the debate does not take several other relevant issues into account.

1. Cost of health care. The average cost of obtaining a reasonable health-related service must be a reasonable multiple of average per-capita income. I realize that there would be a great deal of disagreement about what the word "reasonable" means in this context. But, the way I look at it, current prices of health care are in the realm of the $600 toilet seat. And there is agreement that that is not reasonable.

I listened to a podcast last week about a couple who incurred over $400,000 in medical expenses for a difficult twin pregnancy.

Earlier this year Greg was laid off. Knowing Heather was pregnant with twins, he arranged to continue their coverage with the same provider. They paid insurance premiums directly to the company. The insurer took the money, but after the delivery, they refused to pay the claim. And it is a lot of money: more than $450,000.

That the conduct of the insurance company (United Healthcare) is outrageous is a given.

But, shouldn't we also be talking about what can be done to bring the prices of such procedures to a more "reasonable" level?

2. The case for rationing. When scarce resources must be allocated among a large number of people, there will be rationing. As a society we should strive to allocate those scarce resources as equitably as possible.

As shown in the example above, we have rationing even now. It is just that it is the insurance companies that are doing the rationing and it is being done in the most unscrupulous of ways. They refused the medical claims on the flimsiest of grounds after first confirming that the couple was covered, and after accepting the premiums for months without any qualms.

We need to accept that everybody cannot have everything. Only then will we able to think rationally about what needs to be done to make allocation of scarce resources consistent, predictable and fair.

3. What is a covered "medical" condition or what is "medically necessary" care? Last week I watched an ad on TV for a new drug (latisse) that grows the "patient's" eye lashes. I don't know if this would be covered by insurance. I feel that such medicines - solutions in search of a problem - should NOT be covered. The same goes for a different prescription drug that removes facial hair (vaniqa). And even viagra.

4. Insourcing and offshoring health care and pharmaceuticals. If the cost of health care is high, why don't we apply "free market" ideas to this industry and add more practitioners? We could create new medical schools and flood the market with more primary care providers, we could import ready, willing and able doctors from other countries, and we could send patients to other countries where care is cheaper. As for pharmaceuticals, we could import them from where they are available for the lowest cost. What is good for manufacturing and IT should be good for health care. No?

5. Why are republicans (or at least the reasonable ones among them) not troubled by health insurance tied to jobs? I would have thought they would be in favor of anything that relieves employers of the burden of providing health insurance to their employees, and making businesses better able to compete in the global marketplace (which is the holy grail that is, these days, used to justify any pro-corporations stance - like "too big to fail") .

6. What is the opportunity cost of high health care costs? In other words what are we foregoing because of the crazy way in which it is currently structured? There is a great hue and cry every time there is an attempt to increase the minimum wage. The argument is that businesses will hire fewer workers. I don't agree with the argument when it comes to the minimum wage. But, extending the same argument, I cannot help wondering about the effect of the high cost of health insurance costs on the economy's ability to create and sustain jobs.

By the same token, surely the high cost of health care reduces consumers' ability to spend money on other goods and services. Which again ties into the health of the economy and its ability to create jobs.

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I wish there were published tables of what insurance will pay for each procedure. This would give patients and their families the opportunity to rationally elect the procedures they want even though some of those procedures are above and beyond what the "system" will cover. And, it would permit patients and their families to live and die with dignity.

After all is said and done, isn't that what all this is about?

Festival of lights - Diwali

Sat, 17 Oct 2009 15:10:27 -0400

Today is Diwali, the Hindu festival of lights. Separated as I am, from the "mother" culture, and the community that observes such holidays here, I realized that the day is near only about a week ago.

There are many web sites out there that describe the religious, cultural, and business significance of the day. So I won't go into that.

Rather, I feel like writing about the two aspects of Diwali that mean the most to me and that I am missing today.

One is rangoli, the art of adorning the home by drawing patterns and coloring them in. The other is bhau beej - the day I interpreted for my kids as "sibling day" - the day for celebrating the bond between brothers and sisters.

As a kid I loved drawing rangoli (a new one for each of the 4-5 days of Diwali) on the small veranda of my house. When I was younger, I drew small patterns (6-10 dots per row/column) that required only straight lines. As I grew older, I drew more complex motifs - 30 dots square and using curved lines.

I tried drawing rangoli on the porch of my house (in America). The cold October winds blew the colors away. Not to be maudlin, but a metaphor nonetheless for connections and traditions cast to the wind.

The video below is about the festival of rakhi, a different holiday that also celebrates the brother-sister bond. The video does a wonderful job of portraying the love that the sister feels for her brother and the joy she feels as she prepares to welcome him to her home.

The custom was that the brother visited the sister, because it would be difficult for her to get away, given all her family responsibilities and obligations. He would give her a gift - something that would be hers and hers alone.

At a time when women were not independent and did not have their own income, this gesture signified much. Sympathy for her situation, acknowledgment that her birth family had not forgotten her, that the brother would look out for her even after the parents were no more.

My mother was an only child. Her cousins (brothers once removed, as they are considered in Indian culture) made it a point to visit her on this day, just as they did their "real" sisters.

"Don't forget your sister. The string I tie on your wrist is as delicate as breath, and it cannot be broken as long as there is life. If there comes a day when I live in a faraway land, light a lamp to remember me by.... "

I remain hopeful that as they settle into adulthood, my daughter and son will find their way back to this tradition.

----

Pres. Obama observed Diwali and lit the Diwali lamp in the White House. Turns out the tradition was started during Bush II, although Bush himself never attended the celebrations.

I feel oddly unmoved by either news story. I didn't really expect more from Bush II. And I am not particularly surprised that Obama is an active participant.

But, this is an empty gesture - in my eyes anyway. I feel that all such observances are mere lip service to make sure each vote bloc feels relevant and attended to.

I would much rather Obama recognized the solemnity of the times in which we live and acted in courageous ways, taking on the powers-that-be, be it the insurance lobby or Wall Street, to ensure the welfare of all the citizens whose hopes rest in his audacity.

I wish it was less about hyphenated identities and more about universal challenges.

The real spirit of Diwali is: Lead us from Falsehood to Truth; from Darkness to Light.

Slum children in Hyderabad

Guns and Barbies

Fri, 16 Oct 2009 16:10:13 -0400

Note: The following was written about 6 years ago.

A couple of weeks back I bought my 13-year-old son a toy gun. I know, I know... how could I?! I suppose the short answer is that I decided to "go with the flow."

As most parents know, kids have a way of wearing us out with their demands for the doodad du jour. In this case, he wanted a toy gun. He assured me that the one he had researched and decided he wanted was made out of clear plastic and that it was capable of shooting only tiny pea-sized plastic balls.

Having given up many a battle when it comes to such urgent demands - "everyone in my class has it!" or "I will pay for it with my own money" or even "I will do chores to show you how good I can be" - I agreed to go to Sports Authority to look at what type of gun he had in mind.

I confess it felt weird to be in that section of the store. Real guns were inside locked glass cases. There was plenty of other hunter paraphernalia. As someone who has never even seen a real gun, and as someone who worries about how animals are treated and so no longer enjoys going to the zoo or the circus, I felt the way I might feel upon entering a place of ill repute.

After much discussion, I agreed to buy the gun - but I insisted that it be as unlike a real gun as possible. Even so, I felt very self-conscious at the checkout. The more so, when the clerk asked me to sign a document that stated that I was aware that I was buying a firearm. At that instant I almost walked out of the store, sans gun.

Over the two weeks since the purchase, he has played with it only when he has had a friend over - the one who also owns the same type of toy gun. At one point they tried to use a pebble (instead of the store-bought yellow plastic balls), and it promptly got stuck inside the gun. So, they used screw-drivers and pliers to take the gun apart, dislodge the pebble and try to put the gun back together again. Needless to say, at least a couple of precious hours were spent in this exercise. Since he likes working with his hands (we made 3-d jigsaw puzzles and a dollhouse from a kit when he was younger), I suspect taking it apart and putting it back together was as much fun as target practice.

Earlier the boys had tried to stack empty soda cans to make a game out of it - similar to the ones at a carnival. Turns out, the gun is so "lame" that it could not knock off empty soda cans! Finally, once the pebbles are gone, and with school about to start, the gun is about to get put away.

All in all, not a bad outcome from the purchase of an item of dubious merit.

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Interestingly, this is not the first time that I have seen a similar deflation (or repurposing) of an item's value.

When my daughter was in elementary school, having heard and read all the criticisms of the Barbie doll, I avoided buying her the dolls and also avoided buying the dolls as gifts for her friends. Attending only a few gift-opening sessions at her friends' birthday parties brought out the futility of the trouble I had been going to to find wholesome , "educational" toys and games.

The loudest oohs and aahs were heard when a Barbie gift was unwrapped. They emanated not just from the birthday girl, but from all the others as well. The girls took great joy in bragging about how many Barbies they owned - and the numbers ranged from 5 to 25! All this, while my little one had just one.

After one too many such experiences, I was a changed woman. I too started buying Barbies for my daughter and for her friends. It was not so much a desire to "keep up with the Joneses", as much as desire to help her not feel either separate or "less."

It was gratifying to note a couple of interesting phenomena after this change of course.

When a bunch of girls played together, they loved dressing up their Barbie dolls - cutting the dolls' hair was an all-time favorite activity. Changing their clothes and playing with them in the bathtub were close seconds. Along the way, the Barbies became the hedious pieces of plastic that they were underneath - not the impossibly slim glamour girls that the popluar culture was afraid the little ones were glorfiying. And, although the girls referred to the dolls as a personalzed "her", rather than a depersonalized "it", the dolls were handled with much less care than the "baby" dolls.

As with most childhood fads, once the anxiety about being able to own lots of Barbies was diffused, the toy lost its allure.

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Which is not to say that parents don't have control over or a role when it comes to choosing their kids' toys or their friends. When we say "it takes a village", we often mean the support of a community that is needed when it comes to raising children. However, the "village" may not always have all of the same values as the parent.

I have found it easier not to resist the child's insistence to an extreme. Rather, I try to use the opportunity to put forth my own point of view - my doubts and reservations and why I have them. Equally important, I am open to being persuaded otherwise and do listen to the kids' point of view as well. If nothing else, we are all stronger for having considered the other side.

I think that living in the US, especially as an immigrant, I have tended to focus much more than I otherwise might have, on the symbolism of the choices I was making at various points. This point came home to me when, on a visit to India many years ago, my son was given, what else, a toy gun as a gift. I remember being somewhat judgmental and wondering about the taste (naivete?) of the person giving the gift.

Looking back, I feel I was too harsh. The gun culture is quite alien to people who live in India. And so, they have the luxury (innocence?) of seeing it as a harmless "cops and robbers" costuming prop. Much the same way, that I was allowed to "smoke" little candy-flavored cigarettes as a kid growing up in Mumbai.

As for the gun given as a gift, my son was quite clueless about the concept, and he hardly played with it. In fact, we ended up not even bringing it back with us.

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Over the years I have given in (taken the path of, if not the least, certainly the lesser resistance) on a number of issues - ranging from allowing a 9 year old to watch the PG-13 rated movie Titanic, to allowing the kids to have high speed Internet access in their rooms, to allowing the night curfew to be later than I would have preferred. (And of course, the skiing trip which was to come later.)

I am sure my kids would more readily be able to list the items on which I did not give in - I cannot think of a single one!

The founding fathers did not go far enough

Tue, 29 Sep 2009 07:09:02 -0400

This post is inspired by this one by Heather Michon.

***

In the 2003 book, "Empire of Tea", the authors Alan Macfarlane and his mother Iris Macfarlane have written an engaging account of the remarkable history of tea, "the plant that took over the world." The book opens with a chapter titled "Memoirs of a Memsahib" written by Iris.

She has written about the preconceived notions of racial and cultural superiority with which she arrived in India in 1938 at the age of 16. And she has described at length her gradual awakening to the reality of India, especially the hardscrabble existence as well as the quiet grace of the poor workers who worked on the tea estate that her husband managed.

By the mid 1950s she had started working to improve the living and working conditions of the laborers by providing them education and healthcare. She appealed to the Company doctor for more hospital amenities. She writes,

The Company weren't keen on family planning, he said, the more the merrier - it was a mechanism for keeping wages down. With trade unions now compulsory by law, there were a lot of clever dicks around advising the labour of their rights, the best thing was to have a great many people desperately looking for work. However, I would be allowed, within reason, to give family planning advice as long as I didn't expect the Company to pay for the rubber doo-dahs.

When I read this memoir, it was 2003-2004, a time when the debate about abortion was raging in this country in the run-up to the 2004 election.

Having grown up in India, and being no stranger to the scarcities of opportunity (education, health, leisure) and resources (space, food/water, clean air) that go with having a large population, I firmly believe in family planning. However, I had tended, up to this point, to see the anti-choice agitators as somewhat misguided, but essentially moral people who were willing to work hard for their most cherished beliefs. In fact, I could even persuade myself, in my more generous moments, that there was something admirable about people who placed a higher value on life (even of the the as-yet unborn) than they did on the comforts and conveniences and sheer practicality of having small, manageable families.

But, after reading Iris' account, a light-bulb went off in my head. I came to see that the "Company" - read present day corporations - has a vested interest in having a large population of eager workers. Even though at the time, "globalization" was seen as a new, beneficial at best, and benign at worst, phenomenon (made palatable by Thomas Freidman's "Lexus and the Olive Tree" - "Flat World" would come later), it was not so new after all. The British East India Company, going back to the 1600s, and its offshoots like the company that operated the tea estates in post-Independence India, were really in the business of labor arbitrage: taking advantage of the large numbers of workers to keep wages low while also, by design and neglect (aided by the ignorance and superstition of the workers themselves) ensuring the availability of an almost unlimited supply of workers in perpetuity.

On this background, it was not a great leap to note that religious teachings that advocate against family planning, are essentially operating a) in a model of the world when infant mortality rates were high and life expectancy was low, b) against the interests of women as well as men, and c) to strengthen the hand of the holders of capital, i.e., the corporations.

I came to see that when religions - systems of belief about a higher power, about sin and punya (loosely defined as merit, the Hindu concept that is the antithesis of sin) and about the afterlife - concern themselves more with the hereafter than with the here-and-now, they are actually bound in a most unholy alliance with the moneyed interests and the corporations. The focus on the hereafter comes, too often, at the expense of the here-and-now.

***

As a naturalized American, I admit I am guilty of a certain zeal of the converted. I believe that the "pursuit of happiness" enshrined in the Declaration of Independence was a most original concept not just for its time, but even for current times. Contrast this concept with notions such as sacrifice, duty and suffering which are the preoccupations of Eastern religions, and the emphasis on guilt and sin which are central concepts in the Abrahamic faiths.

Similarly, the idea of the separation of church and state - that is, separating organized religion and civil government - was a truly revolutionary concept. It asserted the belief that the definition of morality in the context of community and government need not be the purview of religion alone.

In light of the insight I gained from "Memoirs of a Memsahib", I have come to believe that the founding fathers did not go far enough. Corporatism was the real scourge of their time and it is so of ours. How else to explain the wanton risk-taking and extreme profiteering on Wall Street and the subsequent protection for the perpetrators in the halls of government? It was corporatism that found justification for slavery, and it was corporatism that found justification for colonialism. What's more, this justification was provided by religion. For, close behind the corporatist raiders were the purveyors of religion. As shown in the Emmy-nominated documentary, Traces of the trade, slavery was made more palatable by converting to Christianity the Africans held in slave forts in Ghana while they "waited" to be shipped to the New World.

"Memoirs of a Memsahib" makes it clear that the debate about abortion is, at its core, nothing more than a convenient distraction. The gullible among us may think it is about higher moral values, and about the hereafter. But the powers-that-be have no illusions. To them, it is very much about the here and now. It is first and foremost about ensuring ample desperate and cheap labor.

What we need is a new Bill of Rights, to bring to fruition the grand experiment launched in 1776. Pursuing happiness, yes. Through separation of Church and State? Not quite.

Separation of Corporation and State, anyone?

Future of self-publishing

Sun, 27 Sep 2009 09:09:52 -0400

This post is my submission to a writing contest on Backword Books about the future of self-publishing.

Having just self-published an anthology, I have some personal experience about the issue, and also an interest in its future.

Like most authors, I came to self-publishing after failing to garner any interest in my book from mainstream agents/publishers and small presses. Each rejection initially put a damper on my dreams, but (fortunately or not), the rejections did not succeed in making me swear off the process altogether.

In previous years/decades, a person in my predicament might have resorted to vanity or subsidy publishing - essentially, paying a printer to print out a couple hundred to a couple thousand copies of the book, and then trying to sell them to friends/famly or giving them away.

The advent of print-on-demand technology at a reasonable price has done away with the need to print a minimum couple hundred or couple thousand copies. At the same time changes in the mainstream publishing industry have meant that many many talented writers are being left out and they have started exploring other avenues to get their creative output in front of readers. Even though most such writers can and probably do have their own blogs, there is something to be said for having a tangible, portable and lasting product.

Finally, there has been an explosion of sites such as Self-Publishing Review and Indie Author that are providing crucial support to self-publishing authors: creating awareness about the model, discussing strengths and weaknesses, success stories, other support services available to authors (book marketing, getting one's book reviewed), best practices and so on. These sites were invaluable to me when I finally decided to take the plunge into self-publishing. Equally, these services have been invaluable in terms of helping me feel less alone in my dream and in my endeavor.

All in all, I think self-publishing has come of age and so it makes sense to discuss its future over the next few decades.

***

The current avatar of self-publishing is very closely tied to the maturation of two unrelated technologies. One is print-on-demand technology which makes it affordable to print one copy of a book at a time. The other is the Internet - blogs and blog collectives which make it easy to read and write eclectic content, connect with others interested in the same niche howsoever tiny it might be, and research issues that one is interested in or passionate about. The Internet also makes it possible to expand the reach of one's creative output through social networking sites and tools ranging from digg and redddit to facebook and twitter.

In the same way, I think the future of self-publishing will be tied to the widespread availability of another technological innovation - reasonably priced e-book readers. Yes, I feel this even though this goes counter to the argument I made above for a tangible and portable book product. Here's how I see it working:

The first change will come when reasonably-priced ($150 and under) e-book readers become available - somewhat like the initial mass market appeal of ipods and the subsequent success of all kinds of mp3 players. The second change will come when the Kindle pricing model is replaced by one that is more rational and reasonable. Something like iTunes for the printed (or rather, the written) word.

I find the Kindle pricing model unappealing for several reasons:

considering that a physical product is not being manufactured and shipped, the (typical) $10 price tag feels exorbitant
a Kindle version of a book cannot be shared with friends
a Kindle version of a book cannot be sold as a used book
the recent flap where Amazon was able to actually delete copies of a book that people had purchased suggested that even at the exorbitant price, the book is not "owned" by the owner

But, I think the key to the success of e-book readers in general and self-published books in particular is contained in my last criticism of the Kindle model.

I expect (hope) that in a few years, the publishing and book-selling model will change as follows:

Book kiosks will become as common as today's photo-printing kiosks). They will be in bookstores of course, bit also in grocery stores, airport lobbies, and possibly in libraries. The kiosk will be a print-on-demand printer and will allow the printing/purchasing of hard-copy books on demand.
The kiosks will also allow books to be downloaded to the customer's e-book reader. This will serve people whose e-readers don't come equipped with Kindle-like Internet access.
The cost of an e-book will be relatively low - in the $3 to $6 range depending on the type of book. The cost of a paperback will be slightly higher - in the $8-$15 range.
The kiosk will also allow e-books to be "returned." That is, the customer will be able to authorize the kiosk to delete a book from the e-book reader. Since this is a digital product, there is no need to find a buyer of the "used" book - in fact, the whole concept of "used" books will be obsolete. The refund will be of the order of 25%-30% of the price of a book. It will be possible to apply the refund to a subsequent book (hard copy or e-book) purchase.
In particular, the kiosk will allow customers to purchase a print-on-demand copy of one of the books in their e-readers, at a discount over the full hard-copy price.
Alternately, publishers will have a special price for "non-returnable expiring" books. That is, for a discount, an e-book will be automatically deleted from the device after a preset number of days.

In other words, we will be essentially "renting" most of our (e-)books, and actually buying (that is, not returning) only the ones we want to have in our permanent (or longer-term collection). This has several advantages:

The total cost of reading a number of books will be significantly less than the cost of owning each one of those books.
Readers will be more open to trying new/untested authors/genres because of the lower risk associated with "buying" what may end up being a disappointing book. (This has been my experience with Netflix - I get movies that I might not have considered if I was paying a per-DVD fee. At the same time, watching a wide range of movies, even movies to which I give just two stars, have made me a more informed world citizen and a more sophisticated movie fan.)

All in all, books published by mainstream publishers will not have an advantage in terms of cost of printing and cost of shelf-space in bookstores. Over the next couple of decades I see self-publishing offering an increasingly level playing field to aspiring authors.

Creating mass awareness about self-published books (beyond their niche) will, unfortunately, remain a challenge.

***

April Hamilton who writes the Indie Author blog has written about how in the future self-publishing will become a pre-requisite for mainstream publishing:

I predict that within 5 years, self-publishing will no longer be an option, but a prerequisite for unknown, aspiring authors hoping to land a mainstream publishing deal. It’s the logical, inevitable next step in author platform.

In other words, the low entry cost of self-publishing will mean that mainstream publishers will themselves come to rely on self-publishing to help them identify titles to be sold and promoted by them.

This will, in turn, only enhance the profile and legitimacy of the self-publishing model.

***

Over the longer term, I see a few other exciting possibilities for self-publishing.

One: on sites like Open Salon, I often find compelling blog posts from a variety of authors (link, link, link). While I am not generally interested in purchasing/saving all the blog posts from a single author, I can very well imagine creating a "custom" book of my most favorite blog posts - to savor later, to save as a snapshot of what I was reading/enjoying during a certain period of my life, and so on. Open Salon (and other sites like it) could create a "shopping cart" model to allow readers to create their own custom anthologies: add individual posts (with or without comments) to the cart and then have the resulting book printed, bound and shipped to the buyer (or downloaded with copy-protection/drm to the customer's e-reader). (Note to Open Salon: if you do end up creating such a platform, don't forget to send some moolah my way ;-) ) Thus self-publishing (enabled by the right technologies) offers a way for even occasional authors to receive a level of validation and compensation that is currently simply not possible.

Two: School and college textbooks are exorbitantly expensive and unwieldy. Self-publishing will allow teachers and professors to compile their own texts based on selected book chapters, online sources of research/reference, blog posts, and so on. In addition to being cost-effective, this will allow for constantly updated textbooks, without the associated "new edition" shenanigans that are currently the norm.

Three: I have come to see self-published books as the creative output of literary artisans. That is, where goods manufactured in factories have one kind of perfection, artisan-produced arts and crafts have their own charm and are infused by the creative energy of the hearts and minds, eyes and fingers of the artist who created the artwork. I feel the same sense of wonder about the self-published books that I have read. I find them free of filtering and reconstruction in the quest for mass appeal and faux exotification. One such book is Afghan Journal by Jeff Courter which I reviewed here. Over time, I expect (hope) that more people will become as sophisticated about their book purchases as they already are about the art they hang on their walls.

Four: In the current publishing model, books tend to be bigger in order to justify a higher price. It is akin to restaurants serving larger portions so that diners don't feel too bad about the $11.99 and up menu price. With restaurants and with books, often, I would be happy with half the content for half the price. With kiosk-based self-publishing and the resultant lack of shipping cost, smaller books will be readily accepted. A 150-page e-book for $5.95 will make sense, especially if a return fee of$1.95 is built into that price. This will lead to having more writers, more focused books, more readers.

All this while fewer trees are cut!