Sunday, March 24, 2013

Fiction that will unfortunately be remembered as fact

Thirteen minutes into the Oscar-winning movie "Argo," CIA agent Tony Mendez asks supervisor Jack O'Donnell what happened to a group of Americans when the U.S. Embassy was stormed in Tehran.

"The six of them went out a back exit," O'Donnell tells Mendez, played by Ben Affleck. "Brits turned them away. Kiwis turned them away. Canadians took them in."

That passing reference to New Zealand is rankling Kiwis five months after "Argo" was released in the South Pacific nation. Even Parliament has expressed its dismay, passing a motion stating that Affleck, who also directed the film, "saw fit to mislead the world about what actually happened."

New Zealand joins other countries, including Iran and Canada, that have felt offended by the fictionalized account of how the six Americans were sheltered and secreted out of Iran during the 1979 Islamic Revolution.

Some in New Zealand have taken those words — "Kiwis turned them away" — as implying the country did nothing to help.

In fact, a U.S. State Department document dated Feb. 6, 1980, says "four Embassies — Canadians, British, Swedish and New Zealand — were involved in their protection and escape." The document was posted online last fall by the Jimmy Carter Library and Museum.

And published interviews indicate diplomats from Britain and New Zealand did help by briefly sheltering the Americans, visiting them and bringing them food, even driving them to the airport when they left.

Yet those interviews also indicate that both countries considered it too risky to shelter the Americans for long. That left the Canadians shouldering the biggest risk by taking them in.

Lawmaker Winston Peters, who brought last week's uncontested motion before Parliament, said New Zealanders are unfairly portrayed as "a bunch of cowards," an impression that would be given to millions who watch the movie.

"It's a diabolical misrepresentation of the acts of courage and bravery, done at significant risk to themselves, by New Zealand diplomats," he said.

Affleck could not be reached for comment this week.

During Oscar media interviews last month, Affleck told reporters: "Let me just start by saying I love New Zealand, and I love New Zealanders." He added that "I think that it's tricky. You walk a fine line. You are doing a historical movie and naturally you have to make some creative choices about how you are going to condense this into a three-act structure."

But Affleck and his screenwriter, Chris Terrio, who won the adapted screenplay Oscar, did catch some flak from critics for taking major liberties, especially a heart-stopping — but fictional — airport finale that had gun-wielding Iranian Revolutionary Guards chasing the Swissair plane down the tarmac, with the plane lifting off just in the nick of time. (In reality, the airport exit went smoothly.)

And after the film was made, Affleck took the step of changing the film's postscript, the Toronto Star reported, to more generously credit Canada and its ambassador at the time, Ken Taylor, who protected the Americans at huge personal risk and was uncomfortable with some details in the film.



A big story about racial conflict that gets ignored by the media

Unless you read the Los Angeles Times, you probably have not heard much about the Latino-on-black violence that has been plaguing southern California on and off for many years. Most recently, four Latino gang members jumped a black stranger in Compton and beat him with pipes. The man was visiting a black family that had just moved into the neighborhood; the men who beat him called him n*gger, informing him that blacks were no longer welcome in that neighborhood.

For several days after the beating, crowds gathered on the family’s lawn, shouting racial epithets and throwing beer bottles at the house. They disbanded each time the police arrived but returned as soon as they left. They achieved their goal; the mother sent her children to live with relatives and is packing up to move. According to federal authorities, this is not an isolated incident; Latino gangs have been forcing blacks out of particular neighborhoods all over southern California.

Unfortunately, this is nothing new. Last year I wrote of the 2008 slaying of high school football player Jamiel Shaw by gang member (and illegal immigrant) Pedro Espinoza. The court concluded that Shaw, a standout football player recruited by colleges like Stanford and Rutgers, was targeted because he was black. And I can’t help but wonder: if Espinoza had been white, would more of us know Jamiel Shaw’s name?

Few have heard of this Latino-on-black crime wave because it doesn’t fit the narrative that many in the media perpetuate. Media elitists would have us to believe that aristocratic whites are relentlessly oppressing all racial minorities and causing all of their woes. (Except Asians, whose high levels of education and economic success they find difficult to explain.) Hence blacks and Latinos are supposedly in the same boat: recipients of the short end of the stick in a white man’s world.

There are several dangerous consequences to this cookie cutter approach to race relations. First of all, the disparity of media coverage for certain crimes implies that justice for the black victim of a Latino (or black) killer is a less pressing concern. The murder of fifteen-year-old Hadiya Pendleton in Chicago by Michael Ward and Kenneth Williams (also black) briefly made national news because Pendleton had sung at President Obama’s inauguration. But how many more Hadiya Pendletons are there whose stories will never be told? Deaths of teens like Pendleton and Shaw speak to a much larger, more complicated problem: lawlessness in many urban areas would never be tolerated in a white, middle class suburb.

The one dimensional understanding of race relations also leads to perilous media inaccuracies. Any event that doesn’t fit the narrative of “white oppressor, black/brown victim” must either be forced into that mold or ignored altogether. This is why, when the Latino George Zimmerman (who grew up in a multi-racial family and modest neighborhood) shot black teenager Trayvon Martin, we were told Zimmerman was a “white Hispanic.” This was only the sixth time in its 160-year history the New York Times had used such a term; would they have used it if Zimmerman had been shot by a white man?

Perhaps the most harmful aspect of an overly simplistic approach to race relations is that it presumes that the power to improve the prospects of blacks and Latinos lies solely with powerful whites. If the plight of suffering blacks and Latinos is due entirely to the racist attitudes of whites, then it follows that only a change in those attitudes will improve their standard of living. This attitude trivializes both the power and importance of the families, churches and community organizations that have been so pivotal in lifting successful blacks and Latinos out of poverty.

It is also easier for a journalist to lament the existence of racism than to report on interventions in areas like education and community development that actually work. The politically incorrect truth is that popular government sponsored programs, such as Head Start, have very little impact on outcomes for lower income black and Latino children. Despite receiving over $150 billion in funding, a 2010 study of Head Start by the Department of Health and Human Services concluded that “the benefits of access to Head Start at age four are largely absent by first grade for the program population as a whole.”

What does have a positive effect on at risk youth? Multiple studies, from institutions including Harvard University, have concluded that regular church attendance, even when controlled for income and parental marital status, has a dramatically positive effect on an at risk child’s likelihood to graduate from high school, avoid crime and become gainfully employed. But don’t expect to read that in the newspaper anytime soon.



The Obamacare Revolt: Physicians Fight Back Against the Bureaucratization of Health Care

Dr. Ryan Neuhofel, 31, offers a rare glimpse at what it would be like to go to the doctor without massive government interference in health care. Dr. Neuhofel, based in the college town of Lawrence, Kansas, charges for his services according to an online price list that's as straightforward as a restaurant menu. A drained abscess runs $30, a pap smear, $40, a 30-minute house call, $100. Strep cultures, glucose tolerance tests, and pregnancy tests are on the house. Neuhofel doesn't accept insurance. He even barters on occasion with cash-strapped locals. One patient pays with fresh eggs and another with homemade cheese and goat's milk.

"Direct primary care," which is the industry term for Neuhofel's business model, does away with the bureaucratic hassle of insurance, which translates into much lower prices. "What people don't realize is that most doctors employ an army of people for coding, billing, and gathering payment," says Neuhofel. "That means you have to charge $200 to remove an ingrown toenail." Neuhofel charges $50.

He consults with his patients over email and Skype in exchange for a monthly membership fee of $20-30. "I realized people would come in for visits with the simplest questions and I'd wonder, why can't they just email me?" says Neuhofel. Traditional doctors have no way to get paid when they consult with patients over the phone or by email because insurance companies only pay for office visits.

Why did he choose this course? Neuhofel’s answer: “I didn’t want to waste my career being frustrated.”

This model is growing in popularity. Leading practitioners of direct primary care include Seattle, Washington-based Qliance, which has raised venture capital funding from Jeff Bezos, Michael Dell, and comedian (and Reason Foundation Trustee) Drew Carey; MedLion, which is about to expand its business to five states; and AMG Medical Group, which operates several offices in New York City. Popular health care blogger Dr. Rob Lamberts has written at length about his decision to dump his traditional practice in favor of this model.

"Since I started my practice, I seem to hear about another doctor or clinic doing direct primary care every other week." says Neuhofel.

Direct primary care is part of a larger trend of physician-entrepreneurs all across the country fighting to bring transparent prices and market forces back to health care. This is happening just as the federal government is poised to interfere with the health care market in many new and profoundly destructive ways.

Obamacare, which takes full effect in 2014, will drive up costs and erode quality—and Americans will increasingly seek out alternatives. That could bring hordes of new business to practitioners like Neuhofel, potentially offering a countervailing force to Obamacare. (One example, the Surgery Center of Oklahoma's Dr. Keith Smith, profiled for Reason TV in September, is doing big business offering cash pricing for outpatient surgery at prices about 80 percent less than at traditional hospitals.)

Health "insurance" is more than just insurance; it's also "a payment plan for routine expenses," as University of Chicago business school economist John Cochrane puts it in a superb recent paper. The late free-market economist Milton Friedman pointed out that we insure our houses against fire and our cars against major damage, but we don't also insure ourselves against cutting the lawn and buying gas. That's the main reason innovation almost never makes health care cheaper. Most patients never see the bill for an ingrown toenail removal or a glucose tolerance test, so doctors have little incentive to seek ways to offer their services for less. For simple consultations, why bother with Skype when insurance will pay full price for an office visit.

Insurance plans that cover everything, a situation that came about largely because of a quirk in our tax code, have also led to the "bureaucratization of medical care," Friedman wrote in a 2001 essay, in which "the caregiver has become, in effect, an employee of the insurance company or...the government."

Dr. Lisa Davidson had 8 years of frustration while running a successful traditional practice in Denver, Colorado. She had 6,000 patients when she decided to stop taking insurance and adopt the same business model as Neuhofel. Her patient list has dropped to about 2,000. She used to spend about 15 minutes with each patient and now it's more like 45 minutes. "We're on track to make more money and take better care of our patients," says Davidson. "It's a win-win all around."Dr. Lisa Davidson (pictured to the far right) and her staff

Before adopting direct primary care, Davidson was unhappy working at the practice she had built because the insurance system imposed a way of doing business that resembled an assembly line. "It's true that in 2014, many more people will have insurance, so there will be a profound need for primary care doctors," says Davidson. "You might say I've done a disservice by dramatically cutting the size of my practice. However, if we make it desirable again to be a primary care physician more people will want to do it."

Under Obamacare, more and more doctors are becoming employees of large hospitals, where there will be more control over how they practice medicine. Hoover Institution Senior Fellow Dr. Scott Atlas fears this will cause a brain drain in medicine. "Really smart people want autonomy, and when you take that away it's naive to think you're going to get really bright people becoming doctors," says Atlas. "The best doctors could excel at any profession, so why go into medicine if they won't have the opportunity to be their best?"

When she was operating a traditional practice, Davidson witnessed firsthand how our "payment plans for routine expenses" drive up prices and block innovation. She recalls that one insurance company paid $118 for a routine PSA test. Now that her patients pay the bill directly the cost is $18. Insurance used to pay $128 for a bag of IV fluid. Now Davidson doesn't bother passing on the cost of IV bags because they run $1.50 each.

Dr. Eric Bricker is the medical director at Compass, a Dallas-based company that helps individuals with high-deductible insurance plans. In a previous job, Bricker was a finance consultant for hospitals, giving him firsthand knowledge of how health insurance drives up prices. "When insurance companies and hospitals negotiate," says Bricker, "it's an exercise in horse trading." For example, an insurance company might let a hospital get away with charging $2,000 for an MRI, says Bricker. In exchange, the hospital agrees to charge the bargain price of $2,000 to deliver a baby. "You do that mixing and matching," says Bricker, "and at the end of the day it works out about even."

According to Bricker, this horse-trading method provides an opportunity for hospitals to earn windfall profits: If the hospital gets $2,000 for MRIs, it will start encouraging patients to get more MRIs.

Given how prices are set, it's no mystery why in health care high costs often correlate with low quality. Bricker cites one facility in Dallas, where a 3-tesla MRI (the more teslas, the higher the resolution) can be had for $860, while a nearby facility offers a 1.5-tesla MRI for $2,500. The latter facility stays in business only because many of its customers don't know the difference. They pay the same $20 co-pay wherever they go for an MRI.

So Bricker co-founded Compass, which works with about 1,200 firms to guide their employees to those doctors and testing facilities that offer both high quality and low prices. These employees have an incentive to seek out value because they're responsible for paying a large portion of their own routine medical costs before their insurance coverage kicks in.

High-threshold plans are exploding in popularity, which is a promising trend. According to a 2012 report by the Kaiser Family Foundation, about 31 percent of firms now offer health plans in which patients pay most routine costs out of pocket, like a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA), and 19 percent of covered workers have one of these plans. High-deductible plans go a long way towards unbundling our "payment plans for routine expenses" from the catastrophic coverage that should be the sole function of health insurance.




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