I’m not dismayed anymore. I’m sad. I’m sure I’m not alone. The weasels are in the hen house and have eaten all the chickens and wonder why there are no eggs.

More interesting than the fine is the underlying lie. The company, and apparently the big five are all involved, took money from investors, short sold the investment (this means they bet AGAINST the investor making money), told them how wonderful the packaged securities were and then laughed at them for their folly.

Ho Humm. Business lying as usual. Whats the news here?  We’ve suspected for some time that the SEC (Securities and Exchange Commission) was bought and paid for, but now having raped the American economy and managing to blame the poor outcome on the suckers who bought into their racetrack scheme, the government fails to even slow down this juggernaut.

I agree with comedian Lewis Black who said “You should expect of your leaders what you expect of an experienced canoe guide.  We’re going down that fork in the river and not the other because down there there’s a *#$(* waterfall!!”  What we have are disneyesque leaders pushing us off the cliff like lemmings, to make a ‘good show’.  We should preserve the banks because they’re our salvation. HAH.

I watch, from the poorest census district in the United States, not 40 miles from nearly the richest, with the realization that we have always blamed the poor for our outcomes. They’re the ones who did this. They created the financial collapse, not the liars at the banks, not the conniving realtors who sold properties they knew would never be repaid, nor the investment banks which rolled all this compost into securities, laughing at the unicorns and morons that would buy such stuff that they themselves had bet against! Imagine that.  An so they have left a trail of devastation and destruction that will take years, if ever to recover from. The folks, trusting their employers to look after them had very low social security payouts but good supplemental income from investments made by their employers – now all vanished at the racetracks of the banking world.

“It was the best of times, it was the worst of times; it ws the age of wisdom, it was the age of foolishness; it was the epoch of belief, it was the epoch of incredulity; it was the season of Light, it was the season of Darkness; it was the spring of hope, it was the winter of despair; we had everything before us, we had nothing before us; we were all going directly to Heaven, we were all going the other way.” I’d hope there would be some public outcry, anger at the blood in the streets. How Dickensian this has all become.

But- I digress.

A patient appears at our primary care clinic on Friday. Classic signs of cholecystitis (gall bladder attack).  We hustle her by transport to the emergency room. Monday morning she’s BACK!  At the emergency room, the nice physician gave her the name of several surgeons she could call to have her gall bladder fixed. None take her insurance.

An 82 year old lady lives in her car. Bernie (this is too good) Madeoff with the retirement funding. She can’t afford the taxes. She lives in her car.

A patient comes for diabetic medication, gets a glucometer (to measure the sugar), strips (to use in the machine) but the company doesn’t pay for the lancets to draw the blood from the finger. Urmmmmmm.

A patient drops a heavy object on her foot. She goes (of course) to the emergency room, diagnosed with a fracture but referred to the clinic so that she can have a cast put on.  She is uninsured.   I might add this over a five day period.

A patient comes with a kidney infection. No problem. Antibiotics. Oh – we don’t cover THAT antibiotic.

A patient, finally stabilized on psychiatric medication shows up for a refill. UhOh. You need a prior authorization. What? This patient has  been taking this for a year. No matter. We need to consider the forms (they say) to make sure the patient is getting the best medication. Insurance oversight.

A letter arrived the other day from one of the major drug companies letting us know that they are going to be direct advertising to consumers for certain drugs so that they (the consumers) will know what best to ask for.

A young boy comes having (as children are wont to do) leaped off a picnic table and stepped on some glass. The local ER (no problem) sees the child, recognizes that there is glass ‘somewhere’ in the wound, sews up the wound, and sends the parents off in search of a surgeon who will see them on state insurance. Two days later. They arrive at our clinic looking for guidance. We are fortunate to have some favors to call in. He gets care.

Lest you think out there that is is a factor of my particular city, its not. As I speak with colleagues around the country, this is the rule not the exception. As insurers tighten the profit noose, looking to their bottom lines not yours, this is a frightening and every more common occurrence. As hospital emergency room expenses rise the quest to slide more care out to the community increases. Its shoddy. Its terrible. Its not good medicine, hell its not good care in the third world. It is however our current system.

Healthcare reform may change some of this but we are only at a beginning. I praise Paul for bringing a bit of humour to what is, for me, a very black, dark sad subject.

State legislatures, not to be overlooked are trying their best to carve themselves in our out of the new Heatlhcare bill by blocking advances or by shouting states rights.  With hard economic times, its easy to get voters to hear the shouting but miss the salient points.

We’ve missed the boat, again. Smoke and mirrors and distraction reign supreme. The emperor, or his bill, have no clothes. This does not cover a majority of the uninsured. I’m waiting to see how those who are unemployed, now some approaching the 2 year mark, will pay for this bit of fluff.  The state’s assistance systems were already at a foundering point and shoving the burden to physicians and hospitals for the under and uninsured will only exacerbate the problem.

There’s a bit of shuck and drag going on here. We’re told that we need to work to pass this. We’re told it will bankrupt us. We’re told this is socialism at its worst.  Socialism?

Today one of the walking wounded comes to the clinic. She works 40-50 hours a week, full time  she’s told, at one of the local hospitals. To expedite services the hospital contracts out its housekeeping. The firm, to keep profits ripe,  they don’t pay insurance.  Hmm. Ok. We took what was a paid in-house position, took away the benefits, hired the same folks to do the same job so that the profits would stay as high as maybe ….

I digress. Here’s a full time working person with no insurance.  How is a public option for her, socialism?  From where I sit, we pay into the medicare system.  We pay it in wages and taxes and reap a long term benefit devoid of the need for stockholders to benefit. Although an inconstant fiduciary, generally governments have handled trust funds much better than banks or insurance companies, always looking to the next gaming table, ripening the profits.

If we allow the loud shouts to take back the minimal advances, and I agree its far from perfect, we’ll end up with still more uninsured.  The hidden cost of the ‘uninsured’ long patched over by draining high end payments from private insurers into the unbalanced pot is at an end. The insurance blokes, have cut off that avenue. The uninsured now go to emergency rooms, expensive care, and not much of it.

Emphasis from the Healthcare Plan was on primary care, extending to patients the ability to see and to find competent expert medical care. If we persist at deconstructing the fragile imperfect house, we’ll have but a very expensive house of cards fallen loosely and very expensively apart.  Threats of Medicare cuts are more thunder than substance. We do need government to help us. Watch carefully.

The car had a sluggish start. It was very retro, very cute, very flawed.  The power train with an automatic could scarcely get the car out of its own way. Add a turbo and stickshift and it did go. Fixing the cars, it was my mechanic’s nightmare, was another thing. It would appear that the engine had been dropped into the car without regard for access. After all what fool would want to fix this?  Access to the engine required removing the right side of the car and all the steering gear there. The engine mounts blocked access to such non critical parts as the timing belt adjustment.

I attended school at UCONN (University of Connecticut) which at the time had one of the finest civil and mechanical engineering departments in the country. I have friends from MIT, CALTECH, CASE to name but a few. They seem pretty competent.  Is it possible there’s a large vacuum at Chrysler which sucks the smarts out of the engineering staff, followed closely by the moral vacuum which removes all traces of morality.   I have long thought that American ingenuity can solve most problems.  The difficulty is that American greed removes the problem solving substituting marketing glitz, full of sound and fury, signifying, nothing.

” although the only non-blinded fellows in the room were they. It was the impending release of poor Jeffrey, once the smartest guy in the room, realizing there were more cats to be skinned, er I mean folks to be fleeced. Well Jeff felt he got a raw deal and he, unable to wallow in the spoils.

When first I read of the looting and larceny I thought ‘heads on pikes‘; but I’m not blood thirsty enough for that. Then I watched Lehman implode and the jackals gather at the corpse to pick the sweet meats. Not one of them felt there was any wrong doing. Indeed they were all self righteous. At that time how little we knew.

I’ve generally supported the aims of this administration (nationally), but find myself watching the the internal dealing and the Goldman-Sachs revolving door spinning so fast its really a fan. I once saw a special about how an engineering firm kept their government work on one side of the hall and their civilian contracts on the other, claiming a mehitza of sorts so that the engineers, who otherwise ate in the same mess facilities, used the same parking lots and other than sharing separate entryways, were really not at all co-mingled. Right.  When the former chieftans of Goldman Sachs run not only the regulating agencies but are also judge and jury I wonder. Hmmm. Right.

There is not an ‘appearance of wrongdoing’. It is offal on the table, and it would appear to be us, the American public. Perhaps I should revisit my former thoughts. Heads on pikes seem not so bad

Some days ago a new face appeared in my care. Ragged on the edges, worn but still under the veneer of the street, a once proud person. She tells me she worked all her life, perhaps 40 years or more, receives Social Security, a pittance because she worked at one of the many downtown retail stores, making ends meet, and saving for retirement through a store plan. Prior to mall-ville, Hartford, as did many other cities, house a plethora of stores from upscale department to jewelry and electronic palaces. It was a mecca in its time. These folks and hundreds, nay thousands like them retired to small owned homes in the north end. Clean. Neat. A neighborhood in constant transition but with ties to religious and community organizations.  Then came Mr Skilling and his ilk.

Not content to raid the coffers of the gamblers of Wall Street, these folks conspired to use as tokens at the gambling tables the funds-in-trust for retirements. Now gone. Bankrupted. Disappeared.

She tells me that she couldn’t afford the taxes on the house. Predators always scent prey in the winds of fortune. In her case it was a ‘remortgage’ that promised to ‘clear up the debt.’  She lives in her car, however long that will last. She has no relatives in the area but has her ‘church’ and her ‘friends’ who don’t know and she sent me a gimlet stare to let me know that I shouldn’t consider letting them know.

So here we are at the end of all things, accomplishing the American dream, living in our car.

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.

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