Monday, January 25, 2016

Point Guards

Basketball has been part of my life for a long time. Sometimes my attention has waned, especially when I didn't have a dog in the fight, but we certainly have a dog in the fight now with the Golden State Warriors, né Philadelphia Warriors. The Warriors are a revelation, led by a basketball genius, Steph Curry, perhaps the best shooter there has ever been. No, not perhaps, the best ever, plus the rest of what he does. He is also the the best ball-handler I've ever seen. He is a genius.
The team, too, is a work of genius. Their passing is A+, they play a switching defense I love, and as we know, they shoot. Curry's three point shooting is so good that the paradigm of how to win games has changed. The Warriors can rely on the three-pointer. It's not all they do, so much of what they do is superb, but relying on the three pointer and not just including it, is different.
I've always loved to think, who are the best five of all time, who are the best ten? And now, the emergence of Dell Curry's son has prompted once again the debate, who was the best point guard of all time? As soon as Bruce Jenkins wrote his column on that subject on Saturday, January 16, my friend Bob emailed me. Bob has never forgotten the 1960 paper I wrote as a Harvard freshman for General Education AhF (whatever that stood for), or Freshman Writing. Title: “Mr. Basketball.” Subtitle: “Or Why I Hate Bob Cousy.”
So, today, we have email. It took me a while to find Bruce Jenkins' email address – the Chron's website is one of the worst in the world – but I finally found it, incongruously at the end of each article in the paper edition, although as I say you can't find it on the blasted website. So I took the occasion, encouraged by Bob, to email Bruce Jenkins, and to attach the original paper.
Here's the letter I wrote:
Hi, Bruce:
I caught your point guard article of last Saturday. I'm a long time basketball fan, and since I grew up in Philadelphia -- I remember being at my back alley hoop in the late 1940's (!) shooting and yelling "Joe Fulks!" -- I had to notice the inclusion of Bob Cousy in the list.  As a Philadelphian, I grew hating Bob Cousy and the Boston acolytes, our Warriors' rivals.  As a matter of fact, when I was a freshman at Harvard and was assigned a free topic paper for English composition, I wrote the now immortal paper, "Mr. Basketball, or, Why I Hate Bob Cousy."  For your possible interest and amusement, I'm attaching it.  Time flies.
When I was in high school I would finish my homework in time to go down to our pine-paneled den and watch Channel 12 from Wilmington, Delaware, which televised the Big  5.  There I watched Guy Rogers as a freshman on the terrific Temple team and fell in love with him.  If only he could have elevated his flat jump shot, he would have been more than honorable mention on your list!  His passing and speed were so, so good; the plays he ran look like the current Warriors.  I made a case then that he was better than Cousy, but the Celtics team was better than the Warriors, and that was the difference.
And just for the record, I think Oscar was the best guard ever, maybe the best player ever.  It's harder to rate position players in basketball than in baseball, say, because a first baseman is a first baseman, but positions in basketball are more fluid and team-based, so it's harder to compare.  The point-forward, for instance.  Basketball is to sports as jazz is to music.
Finally, quiz question -- when the NBA started, they had to get their teams from somewhere.  Do you know where the first Warriors team came from, what their name was?  If you reply to this email, you get to know the fascinating answer.
Very appreciative of your wonderful sports writing through the years, and I would definitely vote for a lifetime achievement award.
Best regards,

Budd Shenkin

Bruce Jenkins responded:

Budd: In studying the Warriors historically, I did know that they were originally the Philadelphia Warriors, beginning in 1946-47 as a member of the Basketball Association of America (BAA). But don't let that stop you from writing! I greatly enjoy recollections from past years. I vividly remember scoring an excellent seat for a Lakers-Royals game at the L.A. Sports Arena in the 1960s. Between them, Oscar, Jerry Lucas, West and Baylor must have score 150 points. I must confess, though, that I wasn't a Laker fan, rather devoted to the Russell-Cousy Celtics. Just because I was so moved by their sense of teamwork. Best -- Bruce J.

I'm now preparing to post the 1960 Mr. Basketball paper. Watch for it, and with any encouragement whatsoever, further basketball commentary.

Budd Shenkin

Tuesday, January 12, 2016

Between Elizabeth and Hillary

I think it's great that a Jew from Brooklyn who moved to Vermont and calls himself a democratic socialist is seriously being considered for President. It's great, seriously. I like and admire Bernie. I think the only problem is that a Jew from Brooklyn who moved to Vermont and who calls himself a democratic socialist can never be elected President. Ain't gonna happen. Hillary might get elected, but Bernie won't.

Hillary has some strengths, but there is a conflict when it comes to the banks. To my mind, Bernie's attacks on the big banks are entirely merited. No need to rehash the issues, but a very entertaining way to see what the banks are like is to see The Big Short, which I really liked. Den of evil, really. I liked the way Jamie Diamond's picture was flashed at the end with no mention of who or what, just the scent of evil.

Bernie gets this. But Hillary, to all intents and purposes, it seems, does not. He says the banks need to be broken up, she says no, it's more important to go after AIG and other bank-like institutions, hiding and showing off her sophistication in an obfuscation. She is really very lukewarm about it all, and we know that she and Bill have always been cozy with the big banks. Robert Rubin was Bill's pal, the awful Robert Rubin.

So, do I just hold my nose and vote for Hillary (in the general; in the primary, I could still go for Bernie)? Or, do I hope and rationalize?

I have made a decision. I'm going to bravely hope and rationalize. Here's what I'm thinking.

The greatest modern liberator, the greatest effector of civil rights, was Lyndon Baines Johnson, a man of the South. His friends were the Southerners in Congress, Richard Russell most of all, but Harry Byrd also. His sponsors were Jim Crow people through and through. But LBJ had been poor and discriminated against, embarrassed and reviled in his little town in Texas when his father failed in business. He identified with the poor minorities who were discriminated against. Then, when LBJ ascended, he used his power and acumen to do what that little boy had wanted to do, he righted the wrongs, as no one could have predicted he would. LBJ rose with the Southerners and then turned on them, to his everlasting credit.

Now, I want to imagine, what went on in December of 2014 when Hillary met secretly with Elizabeth Warren? People were talking about Warren for President then, although she obviously was wise enough not to want to do it. Still, Hillary wanted to tidily nail down another corner of her tent, so she met with Warren. What went down?

Here's where my rationalization comes in. I think she addressed Warren's viewpoint, which when it comes to the banks is pretty much the same as Bernie's. I think Hillary said that she thoroughly understood Warren's concerns, and she shared them. They were really on the same side. But, said Hillary, it's not so simple. I don't know what all the complications are, but there are many and they are severe, and a lot of them involve money and power that the banks have in abundance. It's not just a question of “Let's reinstitute Glass-Steagall,” I bet. There is a lot that has to be done, a lot of maneuvering, just as when Johnson got the Civil Rights Act and the Voting Right Act passed. And, in addition, before you do anything, you have to get elected.

So, I'm dreaming that Hillary said, “Elizabeth, I know exactly what you're saying, and I'm in your corner. But first I have to get elected, and to get elected I can't show all my cards. And then when I am elected, even then I can't show all my cards. I have to maneuver. But I want you to know, what you want is what I want.

“You can do what you want between now and then. I know you can't be totally and overtly supportive, and actually I don't want you to be. That would probably hurt me. You can support me subtly, until the end when we might need to pull out all the stops. But I want you to know that when and if I get in, I intend to pull an LBJ. It's only right; it would be the best thing to do for the country.”

So, given the state of the Republican Party, I'm going to support Hillary no matter what happens. But meanwhile, I'm rationalizing enough to feel really good about it.

Budd Shenkin

Sunday, January 3, 2016

Trump's Points Aren't All Wrong

I guess the Donald Trump phenomenom is complicated, but to me, some of it is that some of what he says is true. Far from all of it, and more pointing to problems that coming up with solutions – in fact, Trump is virtually a solution-free zone beyond “trust me, if I can't handle it personally we'll look into it closely and I'll get the best possible to handle it.”

Another part of it is style. While he is crass, his directness is refreshing to many. He has the aura of someone who calls a spade a spade. His entertaining and preposterously grandiose style might be at odds with the more circumspect and stately persona we look for in a President, and in the end will surely defeat him, but having a mix of entertaining style and apparent truth-telling has been potent.

When you think of it, actually, it is amazing how poor so many politicians are in public, when communicating to the public is one of their most important functions. Anyone who has taken acting 101 can see that so many of them just blow it. What is your “action,” to be technical about it? Is it to convince, to proclaim, to charm, to dazzle, to intimidate, to find out, what? All these are possible. Even Obama, for all his eloquence, and he is very eloquent, is professorial and declaiming. Bill Clinton convinces pretty well by 'splaining, that's in his wheelhouse. Hillary yells and is combative, and that's not being sexist, she yells at you. Others speechify. Others try to be charming by saying aw, shucks. George Bush was one of the worst; he talked to someone else beside you who were listening, seemed to me. But I digress.

Trump makes his points in an oppositional, the-king-has-no-clothes style (“they're stupid, am I right?”) that is designed to pull you in as a likeminded viewer who understands that the pezzonovente have been pulling fast ones all along. But some of them are right. When he describs a problem with outrage, there have to be people out there saying, “Yeah!”

So I was just thinking, what would I do with the surprising strength of his candidacy if I were on the questioners panel at a debate – Republican or Democratic? I think I'd use some of his points that I think are right to steer the debate. So, here is what I might do. It might be a fun game for you, as you follow his progress, to think how you might add to the list.

Recommended questions for questioners of presidential candidates

My intro: “While Mr. Trump has been derided as a grandstanding agent of chaos without real policy prescriptions, nonetheless, many of his pronouncement seem to resonate with many Americans. Without getting into personalities, could you please respond to some of the issues he has raised?”

#1. Mr. Trump has stated that our system of financing elections makes for a broken political system. He has stated that politicians without great personal wealth are dependent on donations from persons and corporations who expect a great deal in return.

Do you agree with this view? Do you think the election financing system is broken? Are candidates compromised by the need for large contributions? What changes are needed and would you support?

#1a. Mr. Trump has indicated that much of government is virtually owned by the rich. Do you agree?

#2. Mr. Trump has stated that the United States has been repeatedly out-negotiated in trade and other agreements. He has stated that our negotiators, both elected and appointed officials, are not of the top rank, are soft, and indeed are often “stupid.” He has stated that he would find “the best” personnel in the private sector and drive agreements that were more in the interest of the United States. Do you agree with his assessment? What would you do about it?

#2a. Do you think our governmental personnel are of the first rank, or do you think our first rate people are predominantly in the private sector? Also, would you please answer this question directly in terms of technology? And what would you do about it if you agree that this is a problem?

#3. Mr. Trump has decried an unfair tax system that extracts too much money from everyone. But one important point he has not been alone in making is that it is a scandal that certain investment institutions have been able to benefit unfairly from “carried interest.” Do you agree that carried interest is an unfair tax rule? If so, would you do anything about it?

#4. Mr. Trump has stated that the Iraq war was a terrible mistake, and would much rather have invested the trillions invested in Iraq in domestic priorities of infrastructure, especially roads, bridges, and airports. He has stated that the United States should cast a much less substantial shadow in foreign affairs, and induce other countries to shoulder more of the burden. Do you believe the war was a mistake? If so, do you believe it was avoidable? Do you believe that the United States should stay home more?

#5. Mr. Trump has said that our openness to immigration, both legal and illegal, has sold out our working class to the interests of the wealthy. Do you agree, or do you thin the Trans Pacific Partnership is a good idea?

In sum, Trump does have some challenging ideas, seems to me, despite lots of the vile things he has said, and his terrible low class demeanor. If I were a questioner, I might capitalize on it.

Budd Shenkin

Monday, December 28, 2015

Learning From Your Patients

Some of my best learning moments as a clinician came when a patient left me.  They liked me enough, and respected my trying to meet their needs, to let me know personally why they were leaving me.  Early on, one patient listed my faults (which were many!), including not washing my hands before I examined their child.  Another one, later on, told me I was ineffective in dealing with her troublesome child, and had me read "The Difficult Child" by Henry Turecki, which is a great book that I have recommended to all my patients ever since.  It was painful, but I learned.
And then there was the patient I had with repeated bouts of acute abdominal pain.  I had them come into the office, against their will since they thought I should be able to do it over the phone for free.  I looked at the kid, I thought about it, I walked around the room, and I said, "Does he chew sugarless gum?" 

"Why, yes, he does!" they said. 

"It could be the sorbitol," I said. 

They cut out the sugarless gum and no more stomach aches!  One of my best diagnoses.  I had been studiously reading my newsletters in pediatrics, and it paid off.
The next thing I heard from them was a notice requesting that their records be transferred to a doctor nearer their house.  So I called them up to ask why they were transferring.  They said something about the distance.
I said, "What about that diagnosis that cured the abdominal pain?"
They said, "We expect that!"
What a world.  
Budd Shenkin

Tuesday, December 15, 2015

Ta-Nehisi Coates: Between The World And Me

I just read another book I wouldn't have read except for my book club, Norm's Bookies, having assigned it. In a close vote we chose the widely acclaimed Between the World and Me, by Ta-Nehisi Coates.

The last two years have been filled with evidence of the pervasiveness of police terrorism towards African-Americans. It's incontrovertible – Baltimore, Staten Island, Ferguson, Cleveland, Chicago. All together, the picture is of police terrorism toward African-Americans.

What we have seen in these killings is the outside view. What Coates presents us with is the inside view, what terror lurks in the heart of the oppressed. He, and other African-Americans, need constantly to be on the alert, not at the wrong place at the wrong time, not pissing off the wrong cop, staying under the radar. His friend from Howard, Prince, didn't do that. He wasn't offensive, but he probably was obvious and true to his name, princely. An off-duty Maryland cop stalked him into Virginia and killed him and got away with it. That's not an aberrance, that's the standard, there are many like him, this was just the case closest to Ta-Nehisi.

Stay alert, keep your head down, know where you are. That's really no way to live. He looks at the carefree suburbanites and is irritated. Why do they get to live like that, when Ta-Nehisi has to keep his head down? He's right.

He is on less solid ground, I think, when he talks about his body and relates it to history. It's not just in his mind, they can actually kill him, get to his physical self. In slavery, bodies were captured and ruled. Well, yes, it isn't just mind control, that's true. But that is just history, and it isn't just African-Americans, it's everyone in the world. People didn't just assemble and reason together, after all. Gangs got together, ruled the unorganized and fought the other gangs until finally one gang ruled everything. That's the way states began. The treaties came later, within countries and among countries. The Magna Carta was a treaty between the royal gang and the aristocrat gang. In political theory, the sine qua non for a government that works is having a monopoly on violence.

So, yes, it was a brutal world for slaves and a brutal world still for many. But at least now we have regular ways of negotiating differences, and overall, law is a wonderful thing. Perverted in the case of cops and African-Americans, yes, but better than it was, and it will be better still. Not to say that African-Americans need to be patient. Patience is frequently not a virtue, and this is one such place.

But objectivity isn't the strength of the book; the heart of it is Ta-Nehisi's subjectivity. What he remembers so vividly is that his father had a belt up on the mantlepiece, and he lived in fear of that belt. His father used it frequently, saying “better me than the police.” He made sure by stark physical means that his son would not die at the hands of the police by not showing respect, by mouthing off, by not being aware. Ta-Nehisi accepts the explanation of the father he reveres. He gets beaten for his own good.

I hear this with the ears of a pediatrician. And what I hear is, child abuse. When I hear the alert and watchful adult story, I hear in addition to the reality of police abuse, a certain amount of PTSD from child abuse. Maybe it is functional PTSD; maybe it keeps him out of trouble. But it seems all too reminiscent of scars of child abuse.

I am reminded of the sad case of Adrian Peterson, suspended for a year from the NFL for beating his little son. Charles Barkley objected to the league's view, saying they “They don't understand the South.” Maybe it is necessary; maybe it is. It doesn't sound like it's identifying with the oppressor, man kicks boy and boy kicks dog. It might be one way of dealing with police terrorism. But in any case, it leaves a scar.

It is not just a rhetorical device, then, that the book is written as a letter to his son. We serious people take our parenting seriously. We look at our parents, and we look at ourselves as children. We think, how can I do what I need to do with this most important job of my life?

Our parenting has three major influences. Our default is to replicate our own experience; we can't help but do a lot of that. Our major conditioner is our own personalities. We can only do so much, based on who we are. But then the third influence is what we choose to concentrate on, the things that we want to change. We might have to think about it constantly, because it doesn't come automatically. We might make lots of mistakes, and suspect ourselves of not doing it well enough, or constantly enough. But there are things we think we had better do for the good of the child, things we need to correct in our own upbringing, things in which the clay has hardened in ourselves but not yet in our children.

What Ta-Nehisi has decided to do differently is not to beat his son. And he's trying to tell him, look, I'm not beating you, but you still have to be careful, you hear? They are still out there waiting for you. You hear? I don't want you winding up on a slab like Prince, that magnificent presence at Howard. You can excel, I want you to excel, but you be careful. You hear? You hear?

And now in publishing this book, the rest of America – you hear?

Budd Shenkin

Friday, December 11, 2015

Is It Politically Correct To Be Smart?

I had lunch today with a good friend who takes pride in not being politically correct. I always enjoy it.

He told me about a discussion he had with a younger colleague at the University. My friend Bruce was discussing an issue that had come up on constructing a website for a Departmental project. I think it was on a governmental contract. The problem was this: the staff had constructed the website directory and placed the files in a way that a visitor would have trouble finding what he or she wanted. They had divided up the files according to how they had divided them among themselves as they created them, but that didn't accord with the logic of a visitor. No matter the titles they made up for the sections, It's as though one folder could be called “Mindy's files,” another one “Janet's files,” etc. The path to relevant files was impenetrable.

Bruce said to his friend, “The staff just isn't smart enough to do that job. You need the professors to do it.”

His friend replied, “The staff just doesn't have enough experience in the field.”

No,” said Bruce, “they're just not smart enough. Don't be politically correct. They're staff, not professors.”

His friend couldn't bring himself to agree. For him, it had to be a question of experience. Apparently, under the current rules of political correctness, calling one group “smarter” than another is a no-no.

Well, I could agree with Bruce! Love to be politically incorrect, of course, love being a shit-kicker, but also, like to call a spade a spade.

I told Bruce about my experience when I was a two-year doc in the US Public Health Service in the later 60's. Each year a bunch of us came in as commissioned USPHS officers, Lieutenant Commanders we were, for two years not spent in Vietnam. We did bureaucratic staff work, we worked hard, and in my case it was a high point of my life. We worked side by side with the bureaucracy. We weren't seeing patients, we weren't wearing uniforms, we were doing paper work mostly, looking at the medical stuff that came through Health, Education, and Welfare. It was an eyeopener that gave me knowledge of the ordinary that I have used the rest of my life.

In my experience, the top governmental administrators are pretty smart. They have hard jobs. Imagine trying to get meaningful work out of thousands of employees who are GS-9s or 10s or 12s, who chose government work; that's who you have.

So what would sometimes happen is that a problem would come up that the staff couldn't solve. It would be technical, perhaps, it would be involved, but it wasn't at the level that the administrator him or herself could work on personally. But it had to be solved.

So here is what the savvy administrators would do. They would say, “Get a two-year officer on it!”

But this isn't medical,” the staff would say. “A two-year guy won't know anything about it!”

Doesn't matter,” the administrator would reply. “They'll figure it out.”

And they would. It was a selection issue. Doctors are smart. Some are jerks, some are smug, some are whatever people generally are. But they are smart. They had passed the tests. And they would inevitably solve the problems that the career staff couldn't solve. Because they were smart.

And so are professors. Sure, it's nice to say we're all equal. Just doesn't happen to be true. You could explain to the staff what kind of organization you wanted in the website, you could give examples maybe, but at the end, the professors might as well do it themselves. Incredibly enough, some people are just smarter than some others.

Hope that doesn't constitute a micro-aggression.

Budd Shenkin

Thursday, December 10, 2015

The Obamacare 2014 California Report Card

A couple of years ago I made a bet with my friend Herschel Lessin, a skeptical Republican pediatrician of Poughkeepsie, NY, a graduate of Stanford Medical School and Yale pediatrics residency, and no dummy. Obamacare (otherwise known as the ACA) was just starting, and Herschel believed that the health plans would fail, and that insurance rates would rise significantly the second year.

I didn't think so. I thought that insurance companies would be cautious, since their main lines of business would continue to be non-Obamacare policies, and that they would probably make their rates on the higher side to be safer and not lose money out of the gate, figuring they could gain market share later on when the risks were more knowable.

Herschel won. I don't remember if I have yet ponied up the ten bucks, but still, he won. Rates rose the second year. I supposed that companies had gone for market share after all.

But an article in today's LA Times makes me wonder if the actual culprit for rising rates lies elsewhere. Even though Herschel won (and I will pay up!), I think his win might be tainted.

It turns out that three of California's big four health insurance companies made significant amounts of money last year selling individual policies on the ACA California marketplace. Blue Shield was number one in the country, Kaiser number two, and Blue Cross number seven. So there must be something special about California.

It turns out there is. California mandated that the insurance companies terminate their existing individual policies. According to the article:

Amid a national uproar, Covered California defied the Obama administration and required participating insurers to cancel existing individual policies at the end of 2013.
That move created a healthier, more diverse mix of old and new policyholders at the start of the exchange. About 35 other states allowed consumers to stay longer on health plans that didn't comply fully with the new law.
That decision left many states with a smaller and sicker population signing up for Obamacare. Many new enrollees had been denied coverage previously because of pre-existing conditions.
So that's the story. The problem with the other states is that they didn't really adopt the full ACA as a program; they waffled. As a result it looks like the ACA is a failure, with all those companies losing money, and half the Coop plans going out of business. But in fact, their decisions to let people keep their old policies made the ACA plans victims of adverse selection.

But that's not all there is to the story. In the area of health insurance, it's bound to be complicated. Remember, the biggest wager of the ACA was that insurance companies would reform their sharp practices and compete on quality and price rather than aggressive underwriting and policy denials, that old dogs would find new tricks. Did California health insurance companies learn new tricks?

Well, it seems not. Blue Shield – a chronic offender of sharp practices, according to those of us in the field – benefited by the fact that

consumers had difficulty finding a doctor or getting care during 2014. That could have reduced medical claims, boosting the bottom line for companies.

In fact,

Michael Johnson, a former Blue Shield official and now a company critic, said the San Francisco insurer should issue more refunds to customers. "Blue Shield made this huge profit because they hindered access to care."

And in addition, both BS and BC had inaccurate provider directories, which means that when patients went to sign up and they checked to see if their doctors were in the plan they were signing up for, and they saw that they were indeed on the plan, that information was frequently inaccurate, and after they signed up, they had to switch doctors.

And why were the doctors not on the plan? That's because of the infamous “narrow networks.”

The insurance companies would have us believe that the new plan selected superior clinicians who were most economical in the use of resources, the best and smartest doctors. In fact, however, what happened on the ground was, they circulated a rate schedule to the doctors and said to them, will you take these horrible rates for our new plan? Those that said yes were then christened by the insurance companies as the best of the best.

And meanwhile, let's add one more observation about the insurance companies. There was a ballot initiative last year in California to allow the state Insurance Commissioner to negotiate rates with health insurance companies, as most other states allow their IC to do. It lost with huge insurance company (and organized medicine) advertising campaigns against it. But part of the success of the California ACA state plan is that

Unlike most other states, California negotiates premiums with health plans and doesn't allow every insurer into its exchange.

So in summary, it looks like the ACA looks worse nationally than it should because of the adverse selection problem – too high a proportion of the new policyholders represent people who couldn't get insurance before because of preexisting conditions, probably. And in California, it looks like Covered California is a go, although it could do better with regulating the insurance companies and their practices and narrow networks. And it looks like the old dog insurance companies are continuing with their old tricks.

Stupid insurance companies.

Budd Shenkin