I awoke to a story this morning about Jeffrey Skilling. His lawyers want to revisit the case so poor Jeffrey, who ruined the lives not only of stockholders, but his fellow employees by lying and taking their monies would be set free. But I digress.

I work in Hartford, now ranked the third poorest city of its size in the nation. Once it had a thriving downtown and people worked at department stores, in the pre-mall days, with names like G Fox and Company or Brown-Thompson and more. They probably never made much more than minimum wage but worked hard, many of them for 30 years or more and retired with small social security benefits but with a retirement plan that allowed them some leeway to visit grandchildren, keep an apartment or house and generally live a decent retired lifestyle. No high rollers here, just decent hardworking folks.

I spoke to one the other day, now on the verge of losing her house because she can’t make the tax payments. How? Well Jeffrey Skilling’s friends at Morgan Stanley and Lehman Brothers (and many others) took her monies to the racetrack, bet the monies on derrivatives (a fancy name for casino in the stock world). So long as everyone was making 100% returns (you do see where this is going) everyone was happy. Then the day came when someone looked and (((GASP!!!))) the emperor was naked. The whole house of cards fell and with it the retirements and savings of the folks in the North End of Hartford and elsewhere. Oh well. Not to despair. We’re so good (the Skilling-ites replied) that we need bonuses to make sure that we retain all these fine young minds. And so they did. We the people bonused the bettors. If they’d done this at a OTB window they could not have done a better job.

What of my lady in the North End. She, who worked all her life gets to go on assistance. She spoke with me with tears in her eyes.   She’d never taken anything from anyone and now she was forced to accept this.

I’m not the blood thirsty sort; however, I have visions of letting Jeffrey or his ilk, loose in a field with some of the folks they fleeced. Heads on pikes. It might slow the cascade of betting other peoples monies. It might bring some cold comfort to those without heat or shelter because they lent trust and were returned fiduciary irresponsibility.

I spoke with a 401K counselor recently about all this stealing. He of course in his snow-cones-salesman’s way assured me that this could never happen to mutual funds? Huh?

Somewhere out there I recall that fiduciary meant fiscally responsible. If we bonus these people perhaps they should pay (directly) some of those millions to those they fleeced.  An idea but hardly likely to fly. Nope. Heads on pikes I think.

I get a call the other day that a kid has stepped on a piece of glass. Its off hours but I say “sure, bring him in, I’ll take a look”.

A pale frightened 13y/o arrives at the clinic with parents. Apparently yesterday he jumped up off a picnic table (in the way that 13 year old males do) and sprang directly onto a wine glass lying on the ground. The glass shattered into the bottom of his foot. The parents, correctly, take him to the nearest emergency room. He waits approximately 3 1/2 hours since its “only a bleeding foot”. Xrays show glass in the wound and the physician diagnoses tendon injuries to the tendons of the toes. Ahh, you say, a case for the surgeons.

Not so fast. He has a state option child health insurance. They sew up the foot (with the glass inside) and direct him to a private practice clinic the following day. He continues to bleed, slowly, through the night. Mom and dad pack him off to the local recommended doctor only to find that he (nor most others) do not accept this insurance. They are tempted to return to the emergency room but call me.

He cannot be treated here. He needs advanced care which we cannot offer to him. I make some calls with the assistance of our pediatrician. He’s transferred to a tertiary care facility. By 4PM he’s in an operating room and being cared for.

What went wrong? Why didn’t the emergency room transfer him inter-hospital when they realized they had a severe injury they couldn’t handle? Why did they refer him through out patient when clearly there was no real outpatient option?

Insurance. When the insurance pays so poorly that even the most basic of services are covered but lose money, then the hospitals, left to chose to bleed monies or to restrict services chose the latter. In the land of ‘the best healthcare” we are forced into rationing that healthcare based not on need, not on priorities but on the needs of the stockholders of insurance companies.

I have this open ended discussion with my family about this. How is this ‘us’. How did We the People. .. become Us the torturers….. How is this ever right.

I think it comes from trimming a bit off the Constitution, that rather dusty rag of a document which our Founding Fathers found so important. So we don’t really have free speech anymore since big brother listens in on our cellphone, phone and regular conversations with impunity and without warrant. Its that old bothersome ’search and seizure stuff’ those good old boys found so awful from their British masters. Needing a warrant, probable cause and that rather outdated stuff. We need this to be free from terrorists. I’m becoming a bit terrified myself lately.

A young priest named Torquemada started a campaign of ‘information gathering’, a tongue torn out here and there, in the name of state safety. What information did he get. None. Nothing. What information did he in fact want. None. It was a campaign of terror. Torture. Terror. —hmmmm.

Throughout our long human history there are records of those who tortured in the name of state safety, abnegating the safeguards in their particular times, accruing power piece by piece. So, I ask my brood, how did we come from “preservers of democracy” to “torturers”. How do we see ourselves? What are the checks and balances, the ironsights of our democratic process?

Sadly folks, the Puritan’s didn’t have it all that wonderfully. Life was hard but it was short. There were no antibiotics, no x-rays, no casts, no real surgery (with anesthesia). Hospitals were to be avoided as pest houses and physicians themselves at the time knew they did little for their patients. Some cures were probably worse than the diseases.

If we have modernized medicine, why can’t we modernize the way we provide care for our citizens. Why do we in the land of the brave, home of the free, live with a 3rd world medical care system. Sure people come here. The Sultan of Brunei came here and got wonderful care. M. D., a fictional name, in the north end of Hartford got turfed. Hmmm. Would the divide and provision of care have to do with money?

Indeed it does. The wheels grind exceeding slowly for those with limited funding.

As there is increasing talk in Washington about the AMA time clicks by. And to whom are the insurance companies responsible? Ahhh shareholders, the same folks who brought us the current bank debacle, to whom we the people pay extravagant sums so that they can support CEO’s in a style to which they’d like to become accustomed. As there is continued agglomeration of insurers, they flock together, eat each other, thereby decreasing real market competition, in the guise of bringing lower cost to the consumer.

In medicine we speak for the patient. In insurance they speak for the money. There’s an inherent split here. When it comes down to it, shall we authorize care OR shall we make 0.02 for the stockholder, the stockholder and CEO options always win out. Duplicity is the name of the game. When Hurricane Andrew roared across the South Florida Pennisula devastating the area. Aetna group was the major insurer holding more than 4 billiion dollars in losses. That past year they golden parachuted their worthy CEO for 987 MILLION dollars (or there abouts) and then cried the blues that they didn’t have monies for claims. Hmmmm

I personally have run into the dealings of insurers. Serveral years ago one of the Connecticut health insurers sent out a note that all billing should henceforth be sent to a POB in Enfield. We all did send claims there and as weeks went by and no claims information was forthcoming, we were told that the claims were lost or that they should be re-submitted. Whoops. Someone bad in the company made an error and there is no POB in Enfield for our claims. We’re really sorry but you’ll have to re-submit them all over again. Hmmmm

I’ve had several friends who’ve suffered death at the hands of insurers, not in any direct sort of way but the usual games playing with existing conditions and difficult to access portals.

Working in a safety net group we see patients bounced from one provider to another, mostly based on non paying insurances. I think most of us are insulted when the insurers talk about the Medicare program, and how it fails to work. It succeeds with a 5% overhead, a draconian fraud unit, and coverage that most of us envy. Are there faults? Are there fixes to be made? Of course. We can in one swoop, make our system succeed. It needs a government backed program, devoid of usurious profits, not socialism, just good medicine.

We need to recenter the discussion, not about death notes but about how to prevent the needless deaths from an unwieldy bloated system which spends much of its monies not on patient well being but on corporate well being. Straight speak or soon, all the Michaels will be dead

The water comes off the roof so fast that it needs a cistern to slow the flow of the water. Cisterns were installed, thermos bottle looking affairs on concrete pads around the building. Voila, problem solved. Not so fast. The waters, not seen since the times of Noah, overwhelmed even this system digging up the ground. Solution: Riprap, stones to break up the water spilling from the cisterns from the roof. Ahh, architecture.

It is indeed a pretty solution, 4 to 4 1/2 inch traprock. Traprock has an irregular shape with sharp edges and pointy parts. It doesn’t move much. However, it is also about softball sized and easy to fit in the hand. About now there should be a D’oh much like Homer Simpson. Rocks. Windows. I believe the building will soon be in the glass business.

It has been something which when I point this out to people, step by step, they say “OH WOW”. Yea. Tinkle tinkle. Irony rides again!….

For many years the Bureau of Primary Health Care has run FQHCs (Federally Qualified Health Centers), RHC’s and look alikes that serve primary care. The problem for Dr. janda is that much of specialty care hasn’t been included. What Dr. Janda doesn’t say is that he and his specialist colleagues are running away from a share alike program which would reduce very high production incomes for them.

Our health care, such as it is, is in a shambles. We rank below third world countries in our infant mortalities and our ability to care for our sick and elderly. Buy a coffin? Get off it Dr. Jandra, the coffin’s have been lined up for years. We consign our elderly to nursing homes, frequently staff them with the unwilling and untutored and wonder why grandma is worse than when she was at home?

Medical schools have for years been a part of this conspiracy, wondering why we have so few doctors going into primary care (the treatment and health care for most of us). We train physicians for very long periods of time, from medical school through the end of a residency for Family Practice can be eight or more years. The debt burden is usually around $200,000. Specialty care pays much faster, much more quickly than primary care. “Do the math” as they say at Wal-Mart. They know. The average salary for an internist nationally is 160,000 /year. However most solo-practitioners, the most common U.S. model, make about 1/2 that because of overhead and office expenses.

What to do
• We should back away from the fiery rhetoric we know isn’t making progress just polarizing and scaring people.
• We should look at models which work. The FQHC model works well and is supported by the administration. It isn’t making coffins but prolonging life by bringing very high quality care to those who can least afford it.
• We should stop the insurance madness. We need a not for profit insurance system if that is what is to survive.
• Those who have the bully pulpit should be scrutinized for their connections. When unleashed there is a for fee scramble to modify the system to benefit narrow non-patient interests
• Health care access is a right. We are one of the few industrialized nations with disparities this great. This is not about new immigrants, people from other places, it is about us, the American People standing up and doing the right thing

She must be 15, maybe. She swirls out the door of the rattrap that fucntions as home slamming the door, wearing nothing to deceive the immagination. She would be pretty but she has mean and hungry eyes.  They aren’t child eyes of wonder, that luster long gone. The inquisitiveness of memory is locked away. Hunger. Money. Use me. Now.

She clambers to a car, her high heels a misery to satisfy yet another customer. Hunger. Money. Use me. Now.  They are off but it is not long that she appears again, on the street, long legs up and down the block this child lost grown too fast.  And yet again in but a few minutes she is gone from sight. Hunger. Money. Use me. Now.

And so this long afternoon progresses. From time to time, as we all do, I look out my window at some block familiars and some I haven’t and will probably never again see.  They are all hungry. All waiting.  And then she appears but in new colors and new shoes, striding out with her hard child-long-gone eyes.

I see her walk down the block. A throw away child.  I doubt that there is a want ad which reads “Join the fun life, you too can be a street prostitute at 15″.  Yet. There she is.

Hungry. Money. Use me. Now.

So what? So I’m one of the poor schleps that bought a PT Cruiser but had some misgivings about the power train. I put a lot of miles on a car, somewhere around 36000. I bought their extended warranty because it came with ‘lifetime’ oil changes. I figured at 30-40$ a clip and I change oil monthly.  Dutifully I took the car in for changes. Once day I heard a horrible racket from the engine. It was the power steering pump, I later found out. My mechanic looked at the car and realized (he called me under the car) to see the broken front motor mount, the torn highpressure power steering link and the torn oil line. Hmmmm.

Cars are for me rather like black boxes. These even -=I=- with my untrammeled vision could easily see. The oil had been changed a mere 3 days before!  The dealer never did get back to me. I stopped using the oil change service.

The car will last until it dies. I keep it oiled and well fed but I know that time is not on my side. Now that its been orphaned things will only get worse. The fat cats at Chrysler will dine well and sleep without ethics. What saddens me most is that the country I love, the country I fought for, the country I raised my children in is eating itself, or rather being eaten alive by the corporations who made it.

There was a time when things were built to last. There was always a wink and a smile when some things had built in obsolesence. Where are the buggy whip manufacturers, the boom box makers, the 8 track fabricators .. but things were built with an eye toward building customers.

My next door neighbor when I was a kid used to tell stories of his dad who ran a general store in Coventry CT. One of the customers (in the late 1800’s) came in complaining about the axe he had. ‘Best axe I ever bought’ said he ‘ six new heads, seven new handles. Last me a lifetime’.

Trump cards? Isn’t this banking? Isn’t this where the banker sits across the table and says “Well Joe, opening a restaurant is a risky business and we’ll need some collateral” — or so it was in the past. Now we have bankers betting (your house) on 10:1 or 100:1 odds knowing that the worst will be that the government will for a time be paying into their bank. Where are their ethics.

Ahh ethics. It seems that capitalism trumps ethics. Do undo others before they do unto you. The Ivory Tower at Havard spoke several weeks ago about plans to include teaching ethics to the business school. Its the piper teaching the cobra. Once the cobra leaves the nest, well then its just a bunch of snakes isn’t it?

It wasn’t until the sentencing the other week that I got it. Bernie Madoff…. made off with our monies. Too sweet. such onomatopoeia. No one saw the deal too good to be true, 30:1 winnings? Get real folks. Its all about the casino, and we the taxpayer have been at the largest gaming table ever, Bernie and his friends (and there are more no doubt) are pikers compared to the banks and so called financial houses that take our monies and throw it on the international craps table. Oh lost a few billion in that scheme. Not to worry Uncle will back you. . . .and he has.