I currently blog politically/policywise at Obsidian Wings.
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Amygdala will move to an entirely new and far better blog template ASAP, aka RSN, aka incrementally/badly punctuated evolution.
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Above email address currently deprecated! Use gary underscore farber at yahoodotcom, pliz! Sanely free of McCarthyite calling anyone a traitor since 2001!
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I've a long record in editorial work in book and magazine publishing, starting 1974, a variety of other work experience, but have been, since 2001, recurringly housebound with insanely painful sporadic and unpredictably variable gout and edema, and in the past, other ailments; the future? The Great Unknown: isn't it for all of us?
I'm currently house/cat-sitting, not on any government aid yet (or mostly ever), often in major chronic pain from gout and edema, which variably can leave me unable to walk, including just standing, but sometimes is better, and is freaking unpredictable at present; I also have major chronic depression and anxiety disorders; I'm currently supported mostly by your blog donations/subscriptions; you can help me. I prefer to spread out the load, and lessen it from the few who have been doing more than their fair share for too long.
Thanks for any understanding and support. I know it's difficult to understand. And things will change. They always change.
I'm sometimes available to some degree as a paid writer, editor, researcher, or proofreader. I'm sometimes available as a fill-in Guest Blogger at mid-to-high-traffic blogs that fit my knowledge set.
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"The brain is wider than the sky, For, put them side by side,
The one the other will include With ease, and you beside"
-- Emily Dickinson
"We will pursue peace as if there is no terrorism and fight terrorism as if there is no peace."
-- Yitzhak Rabin
"I have thought it my duty to exhibit things as they are, not as they ought to be."
-- Alexander Hamilton
"The stakes are too high for government to be a spectator sport."
-- Barbara Jordan
"Under democracy, one party always devotes its chief energies to
trying to prove that the other party is unfit to rule --
and both commonly succeed, and are right."
-- H. L. Mencken
"Necessity is the plea for every infringement of human freedom.
It is the argument of tyrants; it is the creed of slaves."
-- William Pitt
"The only completely consistent people are the dead."
-- Aldous Huxley
"I have had my solutions for a long time; but I do not yet know how I am to arrive at them."
-- Karl F. Gauss
"Whatever evils either reason or declamation have imputed to extensive empire,
the power of Rome was attended with some beneficial consequences to mankind;
and the same freedom of intercourse which extended the vices, diffused likewise
the improvements of social life."
-- Edward Gibbon
"Augustus was sensible that mankind is governed by names; nor was he deceived in his
expectation, that the senate and people would submit to slavery, provided they were
respectfully assured that they still enjoyed their ancient freedom."
-- Edward Gibbon
"There exists in human nature a strong propensity to depreciate the advantages, and to magnify
the evils, of the present times."
-- Edward Gibbon
"Our youth now loves luxuries. They have bad manners, contempt for authority.
They show disrespect for elders and they
love to chatter instead of exercise.
Children are now tyrants, not the servants, of their households. They
no longer rise when elders enter the room. They contradict their parents,
chatter before company, gobble up their food, and tyrannize
their teachers."
-- Socrates
"Before impugning an opponent's motives, even when they legitimately may be impugned, answer his arguments."
-- Sidney Hook
"Idealism, alas, does not protect one from ignorance, dogmatism, and foolishness."
-- Sidney Hook
"Let me never fall into the vulgar mistake of dreaming that I am persecuted whenever I am contradicted."
-- Ralph Waldo Emerson
"We take, and must continue to take, morally hazardous actions to preserve our civilization.
We must exercise our power. But we ought neither to believe that a nation is capable of perfect
disinterestedness in its exercise, nor become complacent about particular degrees of interest
and passion which corrupt the justice by which the exercise of power is legitimized."
-- Reinhold Niebuhr
"Faced with the choice of all the land without a Jewish state or a Jewish state without all the
land, we chose a Jewish state without all the land."
-- David Ben-Gurion
"...the proscribing any citizen as unworthy the public confidence by laying upon him
an incapacity of being called to offices of trust and emolument, unless he profess or renounce this
or that religious opinion, is depriving him injuriously of those privileges and advantages
to which, in common with his fellow citizens, he has a natural right; that it tends also
to corrupt the principles of that very religion it is meant to encourage, by bribing,
with a monopoly of worldly honours and emoluments, those who will externally profess
and conform to it;[...] that the opinions of men are not the object of civil government, nor under its jurisdiction; that to suffer the civil magistrate to intrude his powers into the field of opinion
and to restrain the profession or propagation of principles on supposition of their ill tendency is a dangerous fallacy, which at once destroys all religious liberty....
-- Virginia Statute for Religious Freedom, Thomas Jefferson
"We don't live just by ideas. Ideas are part of the mixture of customs and practices,
intuitions and instincts that make human life a conscious activity susceptible to
improvement or debasement. A radical idea may be healthy as a provocation;
a temperate idea may be stultifying. It depends on the circumstances. One of the most
tiresome arguments against ideas is that their 'tendency' is to some dire condition --
to totalitarianism, or to moral relativism, or to a war of all against all."
-- Louis Menand
"The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis."
-- Dante Alighieri
"He too serves a certain purpose who only stands and cheers."
-- Henry B. Adams
"The law, in its majestic equality, forbids the rich as well as the
poor to beg in the streets, steal bread, or sleep under a bridge."
-- Anatole France
"When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle."
-- Edmund Burke
"Education does not mean that we have become certified experts in business or mining or botany or journalism or epistemology;
it means that through the absorption of the moral, intellectual, and esthetic inheritance of the race we have come to
understand and control ourselves as well as the external world; that we have chosen the best as our associates both in spirit
and the flesh; that we have learned to add courtesy to culture, wisdom to knowledge, and forgiveness to understanding."
-- Will Durant
"Glimpses do ye seem to see of that mortally intolerable truth; that all deep, earnest thinking is
but the intrepid effort of the soul to keep the open independence of her sea; while the wildest
winds of heaven and earth conspire to cast her on the treacherous, slavish shore?"
-- Herman Melville
"The most important political office is that of the private citizen."
-- Louis D. Brandeis
"If we desire respect for the law, we must first make the law respectable."
-- Louis D. Brandeis
"We can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both."
-- Louis D. Brandeis
"It is an error to suppose that books have no influence; it is a slow influence, like flowing water carving out a canyon,
but it tells more and more with every year; and no one can pass an hour a day in the society of sages and heroes without
being lifted up a notch or two by the company he has kept."
-- Will Durant
"When you write, you’re trying to transpose what you’re thinking into something that is less like an annoying drone and more like a piece of music."
-- Louis Menand
"Sex is a continuum."
-- Gore Vidal
"I contemplate with sovereign reverence that act of the whole American people which declared that their legislature should
make no law respecting an establishment of religion, or prohibit the free exercise thereof, thus building a wall of separation between church and state."
-- Thomas Jefferson, letter to the Baptists of Danbury, Connecticut, 1802.
"The sum of our religion is peace and unanimity, but these can scarcely stand unless we define as little as possible,
and in many things leave one free to follow his own judgment, because there is great obscurity in many matters, and
man suffers from this almost congenital disease that he will not give in when once a controversy is started, and
after he is heated he regards as absolutely true that which he began to sponsor quite casually...."
-- Desiderius Erasmus
"Are we to have a censor whose imprimatur shall say what books may be sold, and what we may buy? And who is thus to dogmatize religious opinions for our citizens? Whose foot is to be the measure to which ours are all to be cut or stretched? Is a priest to be our inquisitor, or shall a layman, simple as ourselves, set up his reason as the rule of what we are to read, and what we must disbelieve?"
-- Thomas Jefferson, in a letter to N. G. Dufief, Philadelphia bookseller, 1814
"We are told that it is only people's objective actions that matter, and their subjective feelings are of no importance. Thus pacifists, by obstructing the war effort,
are 'objectively' aiding the Nazis; and therefore the fact that they may be personally hostile to Fascism is irrelevant. I have been guilty of saying this myself more than once. The same argument is applied to Trotskyism. Trotskyists are often credited, at any rate by Communists, with being active and conscious agents of Hitler; but when you point out the many and obvious reasons why this is unlikely to be true,
the 'objectively' line of talk is brought forward again. To criticize the Soviet Union helps Hitler: therefore 'Trotskyism is Fascism'. And when this has been established, the accusation of conscious treachery is usually repeated.
This is not only dishonest; it also carries a severe penalty with it. If you disregard people's motives, it becomes much harder to foresee their actions."
-- George Orwell, "As I Please," Tribune, 8 December 1944
"Wouldn't this be a great world if insecurity and desperation made us more attractive? If 'needy' were a turn-on?"
-- "Aaron Altman," Broadcast News
"The great thing about human language is that it prevents us from sticking to the matter at hand."
-- Lewis Thomas
"To be ignorant of what happened before you were born is to be ever a child. For what is man's lifetime unless the memory of past events is woven with those of earlier times?"
-- Cicero
"Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it."
-- Samuel Johnson, Life Of Johnson
"Very well, what did my critics say in attacking my character? I must read out their affidavit, so to speak, as though they were my legal accusers: Socrates is guilty of criminal meddling, in that he inquires into things below the earth and in the sky, and makes the weaker argument defeat the stronger, and teaches others to follow his example."
-- Socrates, via Plato, The Republic
"Every gun that is made, every warship launched, every rocket fired, represents, in the final analysis, a theft from those who hunger and are not fed, who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children."
-- Dwight D. Eisenhower
"The term, then, is obviously a relative one; my pedantry is your scholarship, his reasonable accuracy, her irreducible minimum of education, & someone else's ignorance."
-- H. W. Fowler
"Rules exist for good reasons, and in any art form the beginner must learn them and understand what they are for, then follow them for quite a while. A visual artist, pianist, dancer, fiction writer, all beginning artists are in the same boat here: learn the rules, understand them, follow them. It's called an apprenticeship. A mediocre artist never stops following the rules, slavishly follows guidelines, and seldom rises above mediocrity. An accomplished artist internalizes the rules to the point where they don't have to be consciously considered. After you've put in the time it takes to learn to swim, you never stop to think: now I move my arm, kick, raise my head, breathe. You just do it. The accomplished artist knows what the rules mean, how to use them, dodge them, ignore them altogether, or break them. This may be a wholly unconscious process of assimilation, one never articulated, but it has taken place."
-- Kate Wilhelm
"The most beautiful experience we can have is the mysterious. It is the fundamental emotion that stands at the cradle of true art and true science. Whoever does not know it and can no longer wonder, no longer marvel, is as good as dead, and his eyes are dimmed."
-- Albert Einstein
"The decisive moment in human evolution is perpetual."
-- Franz Kafka, Aphorisms
"All of old. Nothing else ever. Ever tried. Ever failed. No matter. Try again. Fail again. Fail better."
-- Samuel Beckett, Worstward Ho
"First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you."
-- Nicholas Klein, May, 1919, to the Third Biennial Convention of the Amalgamated Clothing Workers of America (misattributed to Mohandas Karamchand Gandhi, 1914 & variants).
"Nothing would be done at all, if a man waited till he could do it so well, that no one could find fault with it."
-- Lecture IX, John Henry Cardinal Newman
“Nothing is more common than for men to think that because they are familiar with words they understand the ideas they stand for.”
-- John Henry Cardinal Newman
"Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives."
-- James Madison
"Our credulity is a part of the imperfection of our natures. It is inherent in us to desire to generalize, when we ought, on the contrary, to guard ourselves very carefully from this tendency."
-- Napoleon I of France.
"The truth is, men are very hard to know, and yet, not to be deceived, we must judge them by their present actions, but for the present only."
-- Napoleon I of France.
"The barbarous custom of having men beaten who are suspected of having important secrets to reveal must be abolished. It has always been recognized that this way of interrogating men, by putting them to torture, produces nothing worthwhile. The poor wretches say anything that comes into their mind and what they think the interrogator wishes to know."
-- On the subject of torture, in a letter to Louis Alexandre Berthier (11 November 1798), published in Correspondance Napoleon edited by Henri Plon (1861), Vol. V, No. 3606, p. 128
"All living souls welcome whatever they are ready to cope with; all else they ignore, or pronounce to be monstrous and wrong, or deny to be possible."
-- George Santayana, Dialogues in Limbo (1926)
"American life is a powerful solvent. It seems to neutralize every intellectual element, however tough and alien it may be, and to fuse it in the native good will, complacency, thoughtlessness, and optimism."
-- George Santayana, Character and Opinion in the United States, (1920)
"If you should put even a little on a little, and should do this often, soon this too would become big."
-- Hesiod, Work And Days
"Your Honor, years ago I recognized my kinship with all living beings, and I made up my mind that I was not one bit better than the meanest on earth. I said then, and I say now, that while there is a lower class, I am in it, and while there is a criminal element I am of it, and while there is a soul in prison, I am not free."
-- Eugene V. Debs
"Reputation is what other people know about you. Honor is what you know about yourself."
-- Lois McMaster Bujold, A Civil Campaign
"All that we have to do is to send two mujahidin to the furthest point east to raise a piece of cloth on which is written "al-Qaida," in order to make the generals race there to cause America to suffer human, economic, and political losses without their achieving for it anything of note other than some benefits for their private companies."
-- Osama bin Laden
"Remember, Robin: evil is a pretty bad thing."
-- Batman
Gary Farber is now a licensed Quintuple Super-Sekrit Multi-dimensional Master Pundit.
He does not always refer to himself in the third person.
He is presently single.
The gefilte fish is dead. Donate via the donation button on the top left or I'll shoot this cutepanda. Don't you lovepandas?
Current Total # of Donations Since 2002: 1181
Subscribers to date at $5/month: 100 sign-ups; 91 cancellations; Total= 9
Supporter subscribers to date at $25/month: 16 sign-ups; 10 cancellation; Total= 6
Patron subscribers to date at $50/month: 20 sign-ups; 13 cancellations; Total= 7
...writer[s] I find myself checking out repeatedly when I'm in the mood to play follow-the-links. They're not all people I agree with all the time, or even most of the time, but I've found them all to be thoughtful writers, and that's the important thing, or should be.
-- Tom Tomorrow
"Gary Farber is a gentleman, a scholar and one of the gems of the blogosphere."
-- Steve Hynd, Newshoggers.com
"Well argued, Gary. I hadn't seen anything that went into as much detail as I found in your blog."
-- Gareth Porter
Gary Farber is your one-man internet as always, with posts on every article there is.
-- Fafnir
Guessing that Gary is ignorant of anything that has ever been written down is, in my experience, unwise.
Just saying.
-- Hilzoy
I read Amygdala...with regularity, as do all sensible websurfers.
-- Jim Henley, Unqualified Offerings
Okay, he is annoying, but he still posts a lot of good stuff.
-- Avedon Carol, The Sideshow
Amygdala - So much stuff it reminds Unqualified Offerings that UO sometimes thinks of Gary Farber as "the liberal Instapundit." -- Jim Henley
...the thoughtful and highly intelligent Gary Farber... My first reaction was that I definitely need to appease Gary Farber of Amygdala, one of the geniuses of our age.
-- Brad deLong
Gary is a perceptive, intelligent, nice guy. Some of the stuff he comes up with is insightful, witty, and stimulating. And sometimes he manages to make me groan.
-- Charlie Stross
I bow before the shrillitudinousness of Gary Farber, who has been blogging like a fiend.
-- Ted Barlow, Crooked Timber
Favorite.... [...] ...all great stuff. [...] Gary Farber should never be without readers.
-- Ogged
I usually read you and Patrick several times a day, and I always get something from them. You've got great links, intellectually honest commentary, and a sense of humor. What's not to like?
-- Ted Barlow
One of my issues with many poli-blogs is the dickhead tone so many bloggers affect to express their sense of righteous indignation. Gary Farber's thoughtful leftie takes on the world stand in sharp contrast with the usual rhetorical bullying. Plus, he likes "Pogo," which clearly attests to his unassaultable good taste.
-- oakhaus.com
The only trouble with reading Amygdala is that it makes me feel like such a slacker. That Man Farber's a linking, posting, commenting machine, I tell you!
-- John Robinson, Sore Eyes
Jaysus. I saw him do something like this before, on a thread about Israel. It was pretty brutal. It's like watching one of those old WWF wrestlers grab an opponent's
face and grind away until the guy starts crying. I mean that in a nice & admiring way, you know.
-- Fontana Labs, Unfogged
We read you Gary Farber! We read you all the time! Its just that we are lazy with our blogroll. We are so very very lazy. We are always the last ones to the party but we always have snazzy bow ties.
-- Fafnir, Fafblog!
Gary Farber you are a genius of mad scientist proportions. I will bet there are like huge brains growin in jars all over your house.
-- Fafnir, Fafblog!
Gary Farber is the hardest working man in show blog business. He's like a young Gene Hackman blogging with his hair on fire, or something.
-- Belle Waring, John & Belle Have A Blog
Gary Farber only has two blogging modes: not at all, and 20 billion interesting posts a day [...] someone on the interweb whose opinions I can trust....
-- Belle Waring, John & Belle Have A Blog
Isn't Gary a cracking blogger, apropos of nothing in particular?
-- Alison Scott
Gary Farber takes me to task, in a way befitting the gentleman he is.
-- Stephen Green, Vodkapundit
My friend Gary Farber at Amygdala is the sort of liberal for whom I happily give three cheers. [...] Damned incisive blogging....
-- Midwest Conservative Journal
If I ever start a paper, Clueless writes the foreign affairs column, Layne handles the city beat, Welch has the roving-reporter job, Tom Tomorrow runs the comic section (which carries Treacher, of course). MediaMinded runs the slots - that's the type of editor I want as the last line of defense. InstantMan runs the edit page - and you can forget about your Ivins and Wills and Friedmans and Teepens on the edit page - it's all Blair, VodkaP, C. Johnson, Aspara, Farber, Galt, and a dozen other worthies, with Justin 'I am smoking in such a provocative fashion' Raimondo tossed in for balance and comic relief.
Who wouldn't buy that paper? Who wouldn't want to read it? Who wouldn't climb over their mother to be in it?
-- James Lileks
I do appreciate your role and the role of Amygdala as a pioneering effort in the integration of fanwriters with social conscience into the larger blogosphere of social conscience.
-- Lenny Bailes
Every single post in that part of Amygdala visible on my screen is either funny or bracing or important. Is it always like this? -- Natalie Solent
People I've known and still miss include Isaac Asimov, rich brown, Charles Burbee, F. M. "Buzz" Busby, Terry Carr, A. Vincent Clarke, Bob Doyle, George Alec Effinger, Abi Frost,
Bill & Sherry Fesselmeyer, George Flynn, John Milo "Mike" Ford. John Foyster, Mike Glicksohn, Jay Haldeman, Neith Hammond (Asenath Katrina Hammond)/DominEditrix , Chuch Harris, Mike Hinge, Lee Hoffman, Terry Hughes, Damon Knight, Ross Pavlac, Bruce Pelz, Elmer Perdue, Tom Perry,
Larry Propp, Bill Rotsler, Art Saha, Bob Shaw, Martin Smith, Harry Stubbs, Bob Tucker, Harry Warner, Jr., Jack Williamson, Walter A. Willis, Susan Wood, Kate Worley, and Roger Zelazny.
It's just a start, it only gets longer, many are unintentionally left out.
And She of whom I must write someday.
ALL YOUR HEALTH CARE REFORM BASE ARE BELONG TO US, sez profit-seeking doctors. Because no one is discussing the issues brought to light by Atul Gawande.
The problems won't be cured until we deal with the culture of profit-seeking doctors:
[...] The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.
Gawande found them.
[...] Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
[...]
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.
Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.
Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.
Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.
In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”
“How much?” I asked.
“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.
He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.
Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.
Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.
“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
And that's the problem that none of the health care reform proposals addresses. Hardly the only problem, of course, as has been endlessly discussed. But a crucial one.
ADDENDUM, July 29th, 10:32 p.m.: And here's a fascinating addition to this story:
McALLEN, Tex. — One of the largest sources of campaign contributions to Senate Democrats during this year’s health care debate is a physician-owned hospital in one of the country’s poorest regions that has sought to soften measures that could choke its rapid growth.
The Democratic Senatorial Campaign Committee collected nearly $500,000 at a reception here on March 30, mostly from physicians and others affiliated with Doctors Hospital at Renaissance, financial disclosure records show.
The event was held at the home of a prominent McAllen developer, Alonzo Cantu, a hospital founder, investor and board member who has raised prodigious sums from the Rio Grande Valley for an array of Democrats.
Another event at Mr. Cantu’s home, in September 2007, brought in at least $800,000 for the committee’s House counterpart, the Democratic Congressional Campaign Committee, according to disclosure reports. The House speaker, Nancy Pelosi, was in attendance and cut a ribbon at the hospital’s new women’s center while in town.
The hospital, which is in Edinburg, adjacent to McAllen, is working both sides of the aisle. Its political action committee, Border Health PAC, split $120,000 last year among House and Senate candidates, including Republicans.
Although Congressional negotiations over health care legislation are continuing, Doctors Hospital seems to be getting much of what it wants. Thus far, physician-owned hospitals have been insulated from some of the most onerous potential restrictions in the health care legislation moving through Congress.
Representative Pete Stark, a California Democrat who wants to clamp down on physician-owned hospitals, said their formidable lobbying had helped eliminate his proposal to limit physician ownership to 40 percent at any hospital.
“Particularly led by these guys in Texas, these guys who have been raising tons of money for contributions,” Mr. Stark said in an interview. “I am sure that some of my colleagues have been willing to hear them out.”
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On at least three occasions in the last two months, delegations from McAllen have made the rounds of Capitol Hill to discuss their concerns, and blunt the effects of the New Yorker article.
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One key provision would limit a hospital’s ownership by doctors to the level in place at the time of enactment. That is a change from previous language in House bills to restrict physician ownership to 40 percent. It would have forced Doctors Hospital, where physicians have an 82-percent stake, to be sold or required some of its owners to divest.
Mr. Stark said the change had been made “at a higher pay grade than mine.” The physician-owned hospitals, he said, “just thought they could buy their way out of it, and it’s a sad commentary on the Congress.”
Speaker Pelosi supported the tougher provisions in previous bills but aides said she was willing to accept a compromise to win the new restrictions.
Aides to Senator Max Baucus. Democrat of Montana, the chairman of the Finance Committee, and to Senator Charles E. Grassley of Iowa, the ranking Republican, said the Senate would never have adopted the 40 percent limit and that it was only fair to allow existing hospitals to maintain their ownership structures.
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Whether or not there is cause and effect, some of the hospital’s beneficiaries have passionately supported its position. In November, the South Texas doctors raised nearly $60,000 for Representative Sheila Jackson Lee, a Democrat from Houston. Last week, Ms. Lee, who has a physician-owned hospital in her district, inserted comments in The Congressional Record against restricting the hospitals’ growth. She did not respond to requests for comment for this article.
Disclosure reports show that about 220 donors from the McAllen area contributed to the Senate Democratic committee for the March event. Receipts totaled at least $425,000, about 2 percent of the group’s collections for the first half of the year.
“We’re not naïve,” said Dr. Ambrosio Hernandez, a pediatric surgeon who gave $5,000. “We understand that politics plays a role in everything.”
This is a fascinating post. The idea of anchor-tenants is really interesting.
It makes me think about power as it is wielded in all sorts of areas, including in group dynamics.
The most powerful voice in a group often creates a culture that is difficult to change. Whether or not the most powerful voice is also wise, efficient and flexible depends on the culture that supersedes it. (For example, a gang leader may be more or less aggressive toward police depending on the tactics of the police department.)
Indeed. And I expect almost everybody has experienced some version of "groupthink" leading to problems in one or more venues. This is another subset (or greater set) of that kind of influence.
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