College Student Anxiety - A Research Finding, And A Challenge To Be Met

In an excellent piece of research, my friend Richard Scheffler has shown convincingly that American college students are experiencing an epidemic of increasing anxiety.  

Here is the telling graph:

Percent of Students Diagnosed or Treated with Anxiety Disorder in the past 12 months, 2008-2016

This second graph is also useful:

Percent of Students Diagnosed or Treated with Anxiety Disorder in the past 12 months by Gender and Race, 2008 and 2016

 

 

Richard’s coming article gives evidence that these alarming rates are true and not artifacts, and are, if anything, understated.  Last Thursday he presented the findings at our home campus, UC Berkeley, to a largely student audience with a panel that included both the Chancellor and the director of student health services.  Richard’s figures seemed quite believable to audience and panel alike.

Why is this happening?  There are guesses.  Many students lack money in the present and are heavily indebted for the future; they face insecurity of their housing (some are even technically homeless!), and a surprising number experience food insecurity.  Many students are actually on food stamps, and many visit food banks.  Even with the evident dysfunctionality and inequality of wealth in the United States, this is hard to imagine, but it is fact.  Students also report that they work “too hard,” and compete in how hard they are working and how much sleep deprivation they are experiencing.  This could be construed as a cultural element.

Faced with these problems, many of the students are understandably anxious.  They feel helpless and don’t know what to do about it, or where to turn for help.  They do access health care services for counselling in increasing numbers, taking it as a personal problem, which it undoubtedly is, even if there are systematic forces that conspire to produce their individual problems.

In addition to their insecurities about their present situations, it’s hard to imagine that they are not also insecure about what will happen to them in the future.  Some majors can lead immediately to jobs, but others not, and as we know, even if the economy as a whole thrives, many individuals suffer, especially in the recently-graduated population.  The crisis in student debt has been well documented, and it would be a dull student indeed who would not be aware of that future burden.

The university student population has always been subject to anxiety.  It can be a fraught time of life.  It is often their first time away from home, the first time dealing with so many issues on their own, including deciding on their own evolving personal identity, their increased work load and the consequent need for internal academic discipline.  But Richard’s findings clearly depict that the current students are not in the same situation their parents and grandparents found themselves.  The new anxiety is not like the old anxiety in either form or extent.

What is to be done?

What does one do with this research finding?  Understandably, there are calls to find the “root cause” of the epidemic.  Where is our Dr. John Snow to discover that the Broad Street Pump is the source of the cholera epidemic, and fix it with one dramatic move?  

Alas, the causality diagnosis is unlikely to come quickly, if at all.  The cause is probably multi-factorial, involving influences that vary from nationwide to regional to local to individual, from hard economic facts to softer cultural ones.  And while it’s always good to have an idea of causality, the search can often provide a basis for inaction – the so-called analysis paralysis.  The common cry of “we need more research” can lead to steps that benefit the research community more than the afflicted.

Those of us who have held executive positions are familiar with needing to act under conditions of imperfect information.  What we try to do in such situations is to take a best guess at what will help and pursue that course, while being sure to continue to collect information that will help to correct our course, and to suggest other steps we should consider.  

At Richard’s presentation, with the Chancellor and the director of student health services and all the students and student representatives present, all minds naturally gravitated to the Cal campus.  That’s where my mind turned also.  I thought, what would I do if I ran the UCB zoo?

I think of two different requirements for action: how to organize it, and what to do for initial remedial steps.  Organizationally, it is the responsibility of the leaders to establish priorities, not just by fiat, but in consultation with the membership in the organization.  (I would stay “stakeholders,” but I hate that cliché.)  I would gather the major campus forces  – students, faculty, administrators, parents, alumni, others – and tell them that I propose to declare student anxiety a major problem that needs to be addressed as a very top priority, but would wait briefly for their feedback.  Just that declaration would be important, as the consequences would be substantial.  

Personally, I would opt for an Anxiety Czar and an advisory board with political weight and professional knowledge.  (Just as a plug for my profession of pediatrics, I would include on the board a doctor or two who specialize in the health of adolescents and young adults.)  A high priority job needs a highly qualified leader, highly qualified participants, high visibility to the Chancellor and other university and system leaders, and a generous budget.  Unlike what Obama did with the ACA website rollout, I would ensconce an “A Team” from time zero rather than waiting for a crash and have to fix it.  That’s what a high priority means.  The Anxiety Czar himself or herself would be the most important appointment, and would need to be someone who really knows how to move a large bureaucratic organization with many different centers of power and many different agendas, and who would know how to raise the priority of student welfare, since students frequently reside at the bottom of the list.  

In addition to the advisory group over the Anxiety Czar, I would also have an intermediate group between the Czar and the individual groups, where group leaders, students and administration and health and other professionals could share their insights and experiences with one another, and forward information to the Czar above, and to the individual groups below.  Intermediate groups can be powerful, so long as they are not agents of the power above. 

I could go on about organizational requirements, how the Chancellor should think seriously about how she could and should be personally involved, but I won’t.  Except to say that I would make myself personally visible in meeting individually with student groups, and I would insist that administrative and faculty leaders do the same.  Vulnerability to visible failure is often a motivating force.  Otherwise, I probably don’t know enough about the campus to opine, and specific knowledge of the players is essential.

Operationally, it’s important to think about anxiety both generally and specifically.  Anxiety involves a sense of insecurity, focusing mostly on the future.  It helps the anxious person to feel that someone cares about them, and it’s even better if that someone has some power to act.  At Berkeley specifically, it’s useful to remember the ever-present legacy of the Free Speech Movement.  Behind the ideology, if you listen to the rhetoric, you hear, “no one cares about us.”  One of the most famous speeches in American history – no exaggeration, imho – is Mario Savio’s, and what is he saying?  No one cares about us; we are product to them.  But we are human beings! 

https://www.youtube.com/watch?v=Yew51uYHYV4.

It’s hard not to think that feelings of being overlooked and not cared for, especially in the first years away from home, are endemic to a large university.  And truthfully, it’s a fine line to walk between giving care and intervening unduly, as most parents know.  “Being cared for” is not something that will be fixed by posting signs around campus: “We Care!”  It can be demonstrated by overt steps to solve problems, like housing and food.  But probably most effective will be honest old-fashioned and probably expensive human person to person contact.  

I would recommend especially small group contacts, where students can be reinforced in their feelings of not being alone, where caring relationships can develop, and where at the same time information can be obtained to inform actions from above.  My own plan would be to ensure that each student had at least one small group where he or she would be member.  The leadership of the group would have to be carefully chosen and groomed – leaving groups to pure self-help could be both destructive and ineffectual.  If there were a central unit that would act both for organizing and training group leadership, and also receiving feedback from the groups so that leadership could get better information of where anxiety seemed to come from, and what steps might be working and which ones not, then progressive honing in on effective responses would be enabled.  I would make the network of information flow very visible, and publish continuous summaries on line of what information is flowing, and I would make sure that it is not just information qua information, but information that can lead to action.  

Then, I would publish exactly what actions are being taken on the information.  Students don't just want sloppy kisses of love, they want actions.  An antidote to anxiety is agency.  Is the information being translated into action?  That's the responsibility of the Administration.  In retrospect, wouldn't the administration of Clark Kerr have wished they would have known what the problems in the student body were beforehand, and moved to solve them?  Studying history can lead to improved actions.

The reports of food insecurity are very credible.  If I ran the zoo, I would declare that food insecurity is not an individual problem, but a systematic one, and that the system would be taking responsibility.  There are many ways to get people food.  I would use them.

The housing problems are well known.  If I ran the zoo, I would declare that housing is not just an individual problem but a systemic one.  I would make it the University's responsibility to ensure that decent housing would be available to all at a decent price.  It might involve a severe system change, including University housing registration and allocation of privately held places, and reduced enrollment when sufficient housing could not be located.

Yes, both of these steps on food and housing might be viewed as decreasing student responsibility and learning how to cope in the modern world.  They might be socialistic in tone.  On the other hand, to my way of thinking, it should never have gotten to this stage in the first place.  Is their a better solution?

Medical services have already been decentralized, we heard at the panel discussion.  Counseling and medical attention to mental health are important.  It would be useful to combine the group efforts with these medical efforts and have a continuum of general group, therapeutic group, and individual therapy for anxiety, and for other conditions that warrant attention.  Medical administrators know the difficulty of categorical programs, and how they need to be integrated with comprehensive services.  This common medical administrative problem would be a good reason to include a clinical administrator on the leadership team.

Richard and his group have done a service for UCB and for the university communities nationwide in documenting and highlighting this now apparent epidemic of anxiety in their midst.  There are many research avenues to pursue; further facts would be important.  But it is important to act now.  It is the time for administrative excellence.

One can only hope that the problem is seen clearly and the challenge accepted. 

 

We shall see.

Budd Shenkin     

Vote For Me!

If I were running for the Democratic nomination, here's what I might say:

If only “Make America Great Again” were more than a duplicitous slogan! It's not a bad thing to aspire to. You all know how much I deplore The Trump Crime Family Administration, in all its malevolence. But let's take the slogan that they have made so hateful. Let's compete. What would it take to get America back on track?

Countries should make their citizens safe – safety first! How can we make America safe – not just “safe again,” but “safer than ever?”

• To start with the most obvious: minimize the danger of gun violence. It is a scandal for our children to be learning duck and cover in the schools, for God's sake. We need not only to do the so-called “common sense gun reform,” but let's repossess the combat weapons that are out there, the weapons of mass murder. Let's do what Australia did. And let's renew our efforts to limit guns in cities – there was a Supreme Court decision that said we can't do that, but that was from a very conservative and distorted Supreme Court. That decision shouldn't last forever. Everyone deserves to be safe from guns!
  
  
• Let's make it safe to get sick in America! Health care has been increasingly recognized as a right for Americans, not a privilege for those who have money. The ACA was a great step forward, but it still leaves out too many, and with large deductibles and copays, under-insurance has actually risen! We need increased coverage, and better coverage. Making Medicare a choice for everyone would be a great next step for coverage, and it would also reduce total cost. Add in anti-trust enhancement and lowering drug costs, and you have a much safer America. And don't forget, when conservatives protest that “it's too expensive to expand Medicare,” it's not! Americans are already paying for it, it's just a question of redirecting the payments. Make health care available for all, and America would be getting greater.
  
  
• Let's make America safe on its roads and bridges – physical infrastructure. But infrastructure is more than that. It's also broadband everywhere. And most importantly, we need to make our human infrastructure what it should be – education for all, not middle of the pack or bottom, but best. That means probably doubling the budget for education everywhere, affordable child care so it's possible to study and work even if you're not rich, and making education affordable, including more and more technical education. Without tending to our physical and our human capital, we can't possibly be great. Educated and supported people are safer people.
  
  
• Let's make America safe for breathing and drinking water, let's understand how humans have been burning up the earth, and stop it. To think that business will suffer if we make the earth habitable for our children – all our children – is just an absurd proposition. “Short-sighted” doesn't really capture it – how about “suicidal?” The Green New Deal might not be right in its methods, but it sure is right in its principles, and that's the important part. Climate change needs to be attacked with a vengeance, the way we attacked the Depression and World War II! It can be done while the economy actually prospers, not suffers, if we pay attention to distributing the jobs well, and concentrate of the welfare of everyone, not just the company officials. Extreme weather events will just become more and more severe – avoiding them will actually save a lot of money. Let the business officials earn their salaries and perks by changing their companies in a way that preserves the earth. Now, that would be being great, wouldn't it? Wouldn't it be great to make the Earth safe for our children?
  
  
• Let's make America just. The basis of justice is democracy, and democracy rests on an informed and participative population who vote, without disqualifications. America is changing in the way it looks – as it always has. We started as English colonies, with caucasian stock and African slaves. Then came Germans, and Irish, and Jews, and Eastern Europeans, and Asians, and Indians, and Mexicans, and Middle Easterners, and others. The idea of America is that we do not consist of one racial stock, but that we consist of an idea, which is ever-renewable and updatable. The votes of everyone, unimpeded by disqualifications that simply ensconce the current holders of power, direct how these updates are enacted. The principles of HR 1 need to be passed into law so that justice is increasingly assured. A just America is a safer America.
  
  
• Let's make the world safe again by reuniting with our friends abroad. “No man is an island,” and neither is a country. Countries have more in common than they have against one another. There is no Planet B, and as we make technological progress, there should be plenty for everyone if we work together. They say that good wishes and cooperation is passé, but I don't believe that for one minute. Authoritarianism is always a threat, and now perhaps more than at any time since the 1930's. But if we can rescue America from the threat of authoritarianism, then other countries can, too. We can be an inspiration again. We need to be leaders in standing up for the rights of people everywhere to be safe, and free.

There are other elements of making America great, but these principles are a start. It's a viewpoint; it's my viewpoint. And I believe it is the viewpoint of virtually everyone running for the Democratic nomination for President. What a banquet of great people running for President we have!

Let's not let the Orwellian Trump Crime Family Kakistocracy define what greatness is. They think only of how they can make a profit. Let's not let the Trump Crime Family hijack democracy in a coup using the methods of democracy to undermine it. We still have a democracy, we just have to use it.

I'm looking to what we can do and what should be, and I'm asking for your vote to make it happen.

Budd Shenkin

I Will Keep You Alive: A Cardiovascular Romance

I

I Will Keep You Alive: A Cardiovascular Romance

by Bob and Adele Levin

I've just read a really terrific book. It's a book occasioned by two heart attacks suffered by Bob Levin, the second one so severe that he was placed in an induced coma for two and a half days, seven stents placed, and a mitral valve operation done later on. Heart transplant was discussed. He was very sick. But, as a benefit of the exquisite progress made in modern cardiac care, now, eight years later, he is hardy, healthy, happy, and much wiser and deeper. More and more people are having this experience nowadays, but I've never read an account like this, with scientific accuracy, precise rendering of the feelings at each stage, the details of what being a patient and the wife of a patient entails procedurally, the adjustment of thoughts as the process goes along, and the adjustment of the marital relationship as one helps the other. And most cogently and beautifully described and delineated, extremely importantly and crucially, this is an account of what a great doctor can do for her patient, and what the very best doctor-patient relationship imaginable looks like. This is what great perceiving and writing (and not over-writing!) looks like.

In other words, I liked it a lot.

IWKYA is written in alternating voices of Bob and his wife Adele, who both bring extraordinary qualifications to the job. Although Bob's background as an applicant's attorney for workers' compensation doesn't help a lot – or maybe it does, seeing all those people in need – he is a graduate of the storied writing program at San Francisco State, a terrific professional writer of both fiction and non-fiction, and an established authority on underground comics, of all things. He also knows a lot of psychiatry, probably mostly through Adele. Adele is also a graduate of the SFSU writing program with multiple short story writing credits and is a retired psychotherapist. So they're great writers, not of the flowery type, but of the closely observed and precisely and efficiently expressed variety. And, they have a longtime very close and romantic marriage, dating from the time Bob drove cross-country to find Adele again after they had dated at Brandeis. Who better, then, to write about the new but increasingly common experience of severe illness with successful recovery? To me, this book rivals Joan Didion's The Year of Magical Thinking, which would please them both, since she is a hero to them.

They both describe events clearly and factually, and their reactions at each step. It's the precise description at every step that is extraordinary. The details! So perfectly set out, no overacting, matter of fact with extraordinary facts, including the ordinary indignities of the hospital, where wife's sleeping area can be two chairs pulled up facing each other, here in one of the most profitable hospital chains in the country, Sutter. Read it and weep, administrators – this is your responsibility.

Each step is new to Bob and Adele, but each brings back their personal memories as they struggle with the present, as when Adele recognizes her present fears in light of her long history of fears gathered from her mother's inordinate fearfulness that she passed on. Bob reflects on his mother's too-long life and her debilitation as she dies in the middle of his long ordeal. At each step their pasts inhabit their presents, as is true for all of us, but it's rare for us to see it as clearly as they do. They rise and they fall, they are hopeful and afraid – but this is cliché, and not worthy of how they freshly describe their steps. Let me just say that one will never understand better the step-by-step impact on a close family of the process of acute and severe illness than from reading this book.

Their unstinting frankness is particularly startling and impressive, each matching the other as the voices alternate. They think of each other constantly. They hold hands and kiss. They worry about each other. Bob wonders when he will be well enough to drive so Adele can stop having fender-benders. Well into the process Adele exclaims that what she could really use most is a good orgasm. As he recovers, Bob is disappointed to hear he's not ready for sex, but can console himself with masturbation. These two really have a good marriage. Extraordinary, really.

The recounting of details brings up another point: IWKYA brought home to me again how in so many ways, we have entered the era of Star Trek Medicine. It's amazing how much medicine has accomplished, how these little magic catheters are climbing up inside us and fixing things, how doctors put their fingers into our hearts and mess around with them and have lots of options of what they can do. This isn't the focus of the book, but their precise details make it impossible for the sensitive reader to miss. The world might be going to hell, but cardiac medicine is most emphatically not.

And yet, with all the magic techniques and equipment, where you might think computers and algorithms might take over the decision process, this is far from true. There is still a huge need for human judgement. (Mothers and fathers, you can still urge your children into a medical career! We ain't finished yet! And it's not just the human touch that's important, it's the human brain and the human experience.) Which is where we get to the heroine of the book, cardiologist Louisa Muñoz, known here in the text as Dr. Fleur but then, in a stylistic coup, identified by her real name in the appendix at the end, as though the main text has been fiction, which it most decidedly has not been.

If you read nothing else, read this appendix, where Bob and Dr. Muñoz have lunch, and she reflects on the case. Dr. Muñoz embodies everything we could hope for in a doctor who takes charge of a challenging case. She knows what she is doing – she tells Bob that he is lucky to have her at this time, because she just passed her Boards and so she is completely up to date and hasn't forgotten anything yet – and she cares, she befriends, and all three of them fall in love. But that's after a long introductory period, where she sizes them up (and vice-versa), figures out how she can best serve them, with startling perceptive power. She retains her objectivity, but he represents to her all that she could have hoped for – she saves a patient who would have died, (I Will Keep You Alive, page 159) and he turns out to be a very dear human being. And she turns out to be all that Bob and Adele could wish for, all that any of us could wish for, a caring and immensely capable doctor who takes charge in just the right way. When Bob's mitral valve needs to be evaluated and perhaps replaced, she sends him to the local cardiac surgeon who is technically excellent, but who takes over in such a bumptious and self-important way that she has to wrest control back from him, because she says it's not time yet to operate, that she and not he will decide when it's time, and then sends Bob to another surgeon over in San Francisco who is more sensitive and sensible, and who himself exercises exquisite judgement when he gets into the heart, and figures he can tighten the valve instead of replacing it.

[Note to health policy people – this is why patients have to be able to go out of network!]

This, sports fans, is what we need to appreciate. This is how doctors should work, this is the attitude and the skill they need to develop and maintain, this is the ideal. Teachers of medicine – if I were you, I would make this whole book mandatory reading for trainees, and I would dwell on this appendix.

I could go on. I've been known to go on. I could discuss each of their pages with many more pages of my own and go well over 200 pages for this 164 page book (note that, everyone – a short book long on impact. Teachers – especially good for those med students who were selected for their scientific rather than humanistic abilities, which would be the great majority of them.) But I'm just going to stop here.

I've been a doctor and a policy analyst for a long time, and I've read a lot of medical books. This is one of the very best.

https://www.amazon.com/Will-Keep-You-Alive-Cardiovascular/dp/0997221429/ref=sr_1_1?keywords=bob+levin&qid=1554159797&s=gateway&sr=8-1

Budd Shenkin

Regulating To Fix Surprise Billing And Constricting Networks

About 18 years ago my son Pete had a big accident that took him to the Sutter Roseville Medical Center, the designated trauma center for the American River area where the 4,700 pound live oak tree fell on him. It was a very rocky course, he lost a kidney and had multiple fractures to the lateral processes of his lumbar spine and had a prolonged recovery lasting months, but the spinal cord was intact, his other kidney works fine, and he is alive and well and just gets a sore back sometimes. God smiled on us, is the way we looked at it.

What didn't smile on us was the surprise bill we received from the Sutter Roseville trauma surgery team. They obviously have no competition, since they are the only trauma surgeons at the only trauma hospital in the area. So why should they sign agreements with health insurance companies to join their approved networks, thus agreeing to a fee schedule that generally calls for lower payments for their services than if they had no restraint at all? Why should the hospital insist that they do so when they contract with them; what's in it for them? Fairness to patients? Don't be naive, we're talking about money here.

Despite the fact that we were well insured, we were then faced with many thousands of dollars of fees that the insurance wouldn't cover. This is called “surprise billing.” We protested – I'm a doctor and I don't take these things lying down – and eventually Blue Shield paid since it was an emergency and we really had no choice. Which didn't prevent them from claiming tens of thousands of dollars from the payments Peter received from the insurance companies that covered the liabilities of the parties who were responsible for the tree's having fallen. But that's insurance companies. No wonder they are hated. It is a hatred well earned.

We found out later that our situation was not unique, and today, all these years later with so many families having suffered, “surprise billing” has at long last become an issue to be solved. There are obvious very directive solutions available, such as requiring that all doctors with hospital contracts be part of the networks with every insurance company that the hospital has contracts with, but that has not been our governmental style, when special interests are well represented but people in general are not.

There is another out-of-network issue that is somewhat related and also troublesome. Sometimes you need a doctor or a facility that is outside of your insurance network. It might be a specialized service available only at a university, for instance. Or it might be just a specialist who is of decidedly higher quality than who is in your network. Your insurance company is supposed to negotiate with the needed out of network service provider and pay the bill, but they will predictably object that you really didn't have to go out of network, that the adult oncologist would have been “good enough,” and your child really didn't need a pediatric oncologist, or that their network member was good enough despite the opinion of your primaryc are doctor. Patients might have to fight for this to be covered, it can take a long time, the result is not preordained, and isn't that just what you need when you are dealing with illness, uncertainty about finances? It's really a disgrace, IMHO.

The issue can actually be rather subtle. The best primary care doctors want to act as the patient's medical fiduciary, looking out for the patient's best interest in every way, beholden only to the patient, not to the company who employs him or her, or to the payer. Sometimes, that means finding the best person and facility for the patient with every condition and for every test. Networks, based on who signs up for whatever reason, and those who don't sign up for whatever reason, constrains the ethical duty of the health fiduciary. What can be done to enable the doctor to refer the patient for the patient's best interest, despite network relationships? Something should be done.

In a recent paper in the New England Journal of Medicine, Prowell et al. suggest some remedies for the surprise bill in emergency care, and for paying for the necessary out-of-network care with “inadequate networks,” “without squelching desirable market dynamics,” as the saying goes. (https://www.nejm.org/doi/full/10.1056/NEJMp1815031)

What they propose is “streamlined dispute resolution.” This depends on the health plans and providers submitting to binding arbitration to determine what charges are “reasonable.” Admirably, they turn to the final offer method employed by Major League Baseball for a model.

“In this approach the arbitrator must choose one of the two parties’ final offers, rather than determine the “right” amount independently. Although arbitration has some administrative costs, narrowing the options and disseminating precedents simplifies the process and encourages the two sides to reach a settlement on their own.”

They suggest that this technique could be used in each case when an out-of-network provider who rendered a service refused to accept the insurance company's offered payment, or it could be done prospectively.

While what they suggest would be an improvement over the current restrictive and patient-unfriendly non-system, it's really ridiculous to approach such a systematic problem on a case-by-case basis. Patients just should not be subjected to all this pressure, all this decision-making when they have such limited information. And primary care docs shouldn't have to waste time in fulfilling their fiduciary duty, time that could be better used inputting data to their EHR's. The law and organizations should work for this vital duo, not the other way round.

So, here's what I suggest. One, we need to compel hospital-based doctors to belong to the same networks that their hospital does. That's just got to be the law. What should be the rate of their pay? Well, why not use that same final-offer method? It's true that rates can't just be standard throughout a state or a region; sometimes there are scarcities and sometimes plethoras, and the market needs to be used to find proper rates. I would think the final-offer method should serve that purpose quite well. Exit the surprise billing problem.

Two, out-of-network ambulatory consultations, tests, and even prolonged care needs to be available to the vital duo (primary doc and patient) on a routine basis. One way to do this would be to introduce a law that out-of-network providers be paid at 110% of the rate they are paid by their highest paying network of which they are a member (or maybe second highest?) Not only is this obviously better for patients, but with this increased competitive pressure on networks providers who are currently protected by the assured in-network referrals, the quality of the network providers themselves should improve. It's true that a few providers are members of no network at all; for them, a percentage of Medicare rates could be established, or they could just be generally unavailable ( but only if there were an adequate number of similar providers available.) Presto! Free choice of patient and primary care provider would become much more of a reality, and market competition would be enhanced.

Freedom is a precious thing, but the time for freedom in medicine is long past. It is ruled by oligopolistic insurance companies, oligopolistic providers, and to a lesser extent by government. Our system will be replaced neither completely nor soon; what we need are rules and regs that progressively move it toward true competition in price and quality, and which progressively give patients a better deal. That's what my proposed new rules would do.

It's time to think straight and stop kow-towing to outdated concepts and imperfect understandings, and to show a little courage. Time's a wasting.

Budd Shenkin