• Backlash to the apparent backtrack on global tobacco control

    Two life experiences brought me to blogging and health policy advocacy over the past decade.

    One has been the nine-year experience helping to care for my brother-in-law Vincent, who experiences intellectual disabilities connected with fragile X syndrome. I’ve written about this here many times.

    The second set of experiences were the events that precipitated the joys and heartaches of this caregiving experience: The harrowing deaths of my wife’s parents Janice and Gregory Perrone. Both were smokers, and both died far too young from lung cancer.

    The Obama administration has accumulated a strong, readily-overlooked record in domestic tobacco control. Tobacco taxes—a key tool to discourage teen smoking and to induce smokers to quit—have been increased. The FDA has tightened regulation of diverse tobacco products. The Affordable Care Act expands access to evidence-based smoking cessation treatment. Overall, the administration’s tobacco control efforts may well save more lives than the expansion of health insurance coverage to millions of the uninsured.

    This strong track record sets a high bar for the Obama administration’s global tobacco control efforts—which makes its apparent retreat in global trade negotiations especially noteworthy. As Julian Pecquet describes at the Hill

    The Obama administration is backing away from plans to protect U.S. tobacco-control measures from legal challenges under a pending Pacific trade deal, earning the wrath of public-health groups.

    The Office of the U.S. Trade Representative (USTR) last year suggested creating a “safe harbor” that would have it difficult for cigarette companies to undermine domestic anti-smoking efforts under the proposed Trans-Pacific Partnership (TPP). Instead, critics say, the USTR has opted for weaker language that simply restates existing international trade policy that recognizes countries’ authority to enact health and safety measures.

    This isn’t the worst thing in the world; nor is it particularly surprising in light of past U.S. trade policies. Lydia DePillis describes the rather shameful history in a nice Wonkblog piece. As she points out, both policymakers and an array of American industries have good reasons and bad to seek narrow public health exceptions to free trade agreements. Once a tobacco precedent is set, fast food could easily come next. There’s little doubt that many nations (including the United States) would seek to use such exceptions to protect domestic firms from foreign competitors.

    Still, the Obama administration’s retreat remains disappointing. I’m glad that a coalition of normally-Obama-friendly public health organizations did their best to clobber the administration over it:

    Previously, USTR in May 2012 had announced it would propose new language to the TPP that would have created a “safe harbor” protecting national tobacco control measures from being challenged under the agreement. USTR stated at the time that the proposal would “explicitly recognize the unique status of tobacco products from a health and regulatory perspective….”

    Instead, USTR is abandoning this proposal and has announced that it will offer language explicitly reaffirming that tobacco control measures are included in a provision of the General Agreement on Tariffs and Trade (GATT) that recognizes nations’ authority to enact health and safety measures. This is the first time tobacco would be singled out as being included in the public health exception to the GATT. However, this language is far weaker than USTR’s original proposal, would not cover lawsuits initiated by tobacco companies and would not provide nations that adopt strong tobacco control measures with the protection they need from tobacco industry challenges.

    Mayor Bloomberg, among others, has added to this chorus, too.

    He’s right to be angry, because there’s no more important public health issue in the world. More than 400,000 Americans die every year of tobacco-related causes. Around the world, between five and six million people die from smoking every year. About half of these deaths will occur among adults of working age.

    These huge numbers are almost almost unfathomable. It is as if the combined populations of Chicago and Houston simply disappeared this year. Then San Diego and Seattle were wiped off the map next year, and so on, roughly forever.

    Tobacco misuse remains the leading preventable cause of death and morbidity around the world. Smoking-related deaths are declining in the wealthiest countries, but the situation is much more serious in middle- and low-income countries. The best projections suggest that one billion people may die of smoking-related causes over the next century.

    Rising incomes aggravate the problem.  People have the disposable income to buy cigarettes. The growth of open trade—for so many reasons an incredibly beneficial development—also creates new challenges. It brings cheaper and more-effectively-marketed tobacco products where they have not been sold at the same scale before.

    The United States government has a mixed record in all of this. Our trade representatives have fought to pry open cigarette markets in Asia and elsewhere for American manufacturers. In many cases, American manufacturers were fighting protectionist barriers to reach consumers served by rival firms or by sleepy public monopolies. In other cases, the industry was trying to override regulatory measures of great public health value.

    In both cases, the public health impact of some U.S. government actions was to cause widespread harm. And the problem is more basic than the need to get a few details right. Simply put, trade-liberalizing measures that lower cigarette prices or that induce more vigorous advertising and marketing increase population smoking prevalence, and thus tobacco-related deaths. A growing academic literature underscores this basic point.

    This episode reminds us of something else, too. Open trade is extremely valuable for developing economies, and for the United States. Yet markets don’t always or automatically promote the public good. Some markets–such as the one for cigarettes–cause great harm.

    It’s helpful to start with some moral and practical clarity. As the USTR rightly acknowledges, tobacco is no ordinary product. It causes premature death and serious illness among hundreds of millions of the people who use it.

    This is no ordinary industry, either.  A USTR spokesperson comments: “As we do for other products, we will continue to press for the elimination of tariffs on tobacco, which, by their very nature, discriminate against foreign suppliers.”

    I sympathize with this statement as an abstract matter of trade policy. In an ideal world, every country would implement stringent public health measures applied equally to domestic and foreign firms. In our actual world, I hope our government puts tobacco tariffs on the absolute bottom of the pile. Surely there is some shoelace maker or victim of software piracy more deserving of help.

    The tobacco industry deserves the coolest of civilities, the most stringent of regulations from public authorities. It merits no particular help from our nation’s diplomats and trade representatives, either.

    This episode being a matter of public health, I expect it to fade from the headlines. Politically speaking, it rates about a “1” out of “10” on the Syria/Benghazi/NSA/VMA scale. Still, it’s gratifying to see the Obama administration taking some political heat from its usual allies when it seems to waver on important matters of life and health.

    Some in the administrative might not even mind to see it. As Franklin Roosevelt was once reputed to have said: “I agree with you, I want to do it, now make me do it.” That’s not a bad guide in public health.

    Thanks to Carl Davis from Black Note Tobacco for noting the broken link in this post.


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  • TIE at the movies: The Spectacular Now

    Yeah, I’m stealing a page from my RBC buddy Keith Humphreys, amateur movie review par excellence.

    Emailing with a high school friend, I suddenly recalled a cringe-worthy incident from more than thirty years ago. Riding my bike around the neighborhood, I turned a corner was surprised to encountered my classmate Debbie Chessler. She flashed her beautiful smile, and said, “Hi, Harold.” I responded: “Umm, well, umm, umm, hi.” Since this wasn’t going well, I commenced my exit strategy. Stammering “Sorry, I’ve got to go,” I pedaled furiously away.

    In such moments of befuddled high school crush, I could have used a fun-loving wingman like Sutter Keely, the central character in the lovely film, The Spectacular Now, played with great panache by Miles Teller. (The practicalities of movie-making require particular suspension of disbelief. Teller looks old enough to anchor his own MSNBC show.)


    Never rent a powder-blue prom tux….

    My wife and I saw this film last weekend with our own two wonderful teen daughters. It’s one of the loveliest and (in its way) most serious romantic dramas I’ve seen this year. I was especially struck by the way this film took respected every young person that passed through the frame. We are given to understand that real things are at stake. Important things are happening. Young men and women are trying to face real decisions with real consequences for the rest of their lives.

    This is a love story between Sutter and his girlfriend Aimee, who is played with winning charm by Shailene Woodley. Teen romances are often played for laughs or for their titillating possibilities. Spectacular Now reminds us that high school romance is more substantial and worthy than that. As adults, we carry beautiful and painful memories that can remain surprisingly raw even after decades. It’s so easy to forget this when it comes time for our own kids to explore their own similar experiences.

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  • 4.8 million people uninsured with drug or alcohol problems

    Expanded coverage for substance use disorders is an important, largely-unnoticed features of the Affordable Care Act. ACA will (eventually) cover most of the uninsured. It will also expand the content of coverage through essential health benefit rules and related efforts.

    Through expanded coverage of the uninsured–and expanded coverage for mental health and substance abuse treatment among those already covered–health services researchers estimate that more than sixty million people will eventually see improved coverage for these services.

    How many people with current substance use disorders will actually benefit from these changes? There is no clear answer, but data from the National Survey of Drug Use and Health (NSDUH) provide a useful starting place.

    NSDUH is imperfect. It does not provide detailed income or program participation data. Public use data also mask state identifiers. This infuriating self-sabotage is unnecessary to protect human subjects, and renders NSDUH less useful and more cumbersome than it should be in examining the impact of cross-state policy differences, for example in comparing opt-out and opt-in Medicaid states on ACA.

    Despite these shortcomings, NSDUH is the largest nationally representative survey that includes detailed screening questions regarding drug and alcohol disorders, experiences in substance abuse treatment, reasons for not seeking treatment, and more.

    Figure 1 shows the results for basic coverage. As measured by NSDUH, 38 million American adults were uninsured at the time of the 2011 survey. This figure itself understates the coverage challenge. NSDUH respondents corresponding to another 16,000,000 people report that they have health insurance, but that their insurance plan does not cover drug or alcohol treatment. Presumably respondents sometimes misunderstand complex insurance products. It’s not clear whether expert scrutiny of these same plans would yield higher or lower numbers. The order of magnitude is sensible. ACA’s provisions requiring plans to cover substance abuse treatment–at parity—are thus especially important.


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  • It’s not the age bands I object to. It’s the medical underwriting.

    Austin dissents from my critique of the health reform proposal offered by health policy experts at the American Enterprise Institute (AEI) last week. It seems useful to clarify what we disagree about and why.

    To be sure, ACA is an imperfect project and product. Its authors might be the first to agree that it should go further in curbing regressive tax expenditures, in making better use of comparative effectiveness research, in offering more creative approaches to prevent and address medical injuries and malpractice.

    We’re about to see how imperfect the ACA really is, as the titanic political and administrative struggle over implementation goes live later this year. I share Austin’s fears that the bitter fight poisons our ability to think creatively and fairly about many aspects of health policy.

    As health policy experts, commentators, and advocates, we owe our audience transparency and analytic clarity. Partisan combat, not to mention simple disciplinary blinders, make all of us more intellectually and ideologically rigid than we should be. None of us is fully above the fray. A glossily-published health plan titled Best of both worlds, released at a fancy televised American Enterprise Institute event, is certainly a political object.

    Advocates of universal coverage should think carefully about the prospects of adverse selection undermining health insurance exchanges. These dangers will be especially acute at the origin of such arrangements. Enrollment may be limited. The individual mandate will be weak and untested. Outreach to healthy consumers may be poor. Disproportionate numbers of people with preexisting conditions, participants in state high-risk pools, and others with high expected expenditures may be the first to enroll.

    The mere act of suggesting alternatives and modifications of the ACA in response to such challenges should not be dismissed. Proposals deserve to be evaluated on the basis of their creativity, their feasibility of implementation, and their analytic clarity, not whether, at this moment, they are likely to be implemented.

    I’m dismayed by the plan’s specific content, not by the effort to provide a provocative and useful alternative to the ACA. (I happen to think most Americans would reject the fundamental structure of this plan once its details are presented, but that’s another matter.)

    Despite various flaws, the ACA provides one crucial reform that should be defended: It will dismantle the practice of medical underwriting and associated practices by which insurers pursue risk-selection as a basic business model within the individual and small-group market. Such practices are socially wasteful, since firms expend resources and distort their product offerings to avoid high-cost consumers. These practices also impose heavy burdens and indignities on millions of people.

    These burdens and indignities are so much higher in the United States than in virtually any other industrial democracy. It’s not clear what benefits–if any–our current organization of the insurance market provides to offset these disadvantages. That’s one fundamental motive for health care reform.

    The ACA addresses these problems through (incomplete) community rating, more stringent regulation, essential benefit requirements, an individual mandate, and subsidies to help people with low or modest incomes to afford to do so.

    As Austin rightly notes, the ACA isn’t purely community rated. Smokers pay more for coverage. Older people pay more, too. We might have to tinker with these details to make the new exchanges work.  If the new plan’s authors had called at AEI for larger age-gradients in premiums and for greater subsidies for low-income young people, I would have reacted quite differently to what they wrote.

    But that’s not what they wrote. They call for an experience-rated system, and advanced the idea of “individualized premiums” as a feature not a bug. As Austin writes:

    This is radical. Does that make it a “gigantic blunder”? Considering the plan also includes income- and health-based subsidies and multi-year contracts to guard against reclassification risk, I’m not so sure. I think it warrants consideration, discussion, and analysis.

    So it does. The technical challenges of the proposed system are no less daunting than those confronting the structure produced by the ACA. Once you allow insurers to experience-rate, you rely heavily on regulators’ ability to perform proper risk-adjustment to protect the sick and the injured. The AEI authors don’t say much about the legal, regulatory, and competitive realities of how an overtly risk-rated insurance system would actually function. This is a somewhat different enterprise from the (also-necessary) micro-simulations required to specify costs and subsidies.

    Community rating—albeit with mechanical exceptions for age and for smoking status–sends a clear signal that insurers are not to cherry-pick on the basis of consumers’ individual health histories. This sends a clear signal to consumers too, that they won’t have to answer intrusive questions about the time they sought mental health services after they broke up with their college boyfriend. They won’t have to worry that they will be charged more for insurance because they’re getting fat or have some other health problem.

    Community rating is a promise. The practical challenges to its achievement remain significant. Yet the practical obstacles to individualized premiums are also severe, as are the accompanying risks. It’s simpler and expresses better social values to uproot the enterprise of medical underwriting altogether. That’s a key accomplishment of national single-payer plans. A market-based insurance system that fails to do the same will never fully earn–or really fully deserve–public legitimacy.

    As I noted, it is noteworthy that no wealthy democracy seems to implement universal coverage through individualized premium systems. Several countries implement market-based, community-rated health financing systems. The good ones produce better population health outcomes, provide better protections for the sick and injured, are more economical, and are less administratively complex than our own insurance system. We need to figure out how to do this, too.


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  • “Individualized premiums” Let’s not go there

    Eight distinguished figures in health policy presented an ambitious health plan at the American Enterprise Institute this week. I suspect that you’ll be hearing more about this at TIE. I want to make one quick comment.

    Bullet-point slides present the central pillars of their plan. My friend Hank Aaron was brutal in his role as AEI discussant:

    I find it exceedingly difficult to discuss this proposal for three reasons. First, we are in the midst of a great national effort to implement systemic health reform. That is the business of the day. This proposal seems irrelevant to that debate as it has little in common with any proposal now under discussion by either the political left or the political right. Second, it has design features that I find unappealing but, more importantly, that I am sure would have little appeal to the general public. Third, it leaves unspecified so many essential program elements, that I find it hard to know just what we are talking about.

    And that was just the first paragraph! I share Hank’s basic perspective, though I’d be gentler. Political relevance is not the only lens through which such proposals should be viewed. It’s useful to see an imaginative alternative presented, from such accomplished figures. Even the flaws and the details left unspecified are helpful. If nothing else, the gaps give us greater sympathy for congressional staffers tasked to write the hundreds of pages of junk DNA in health reform bills.

    It’s also useful to be reminded of the need to curb regressive tax expenditures for employer-provided coverage. The key obstacles here are interest-group politics and knotty transition problems, not lack of analytic clarity. ACA’s Cadillac tax was, in its way, a brave effort to bring greater efficiency to public policy.

    Table 3 of their paper presents the deductible structure of a basic, income-related high-deductible plan as they conceive it. I find it clarifying. I suspect many TIE readers who admire the incentive-structure of high-deductible policies would hesitate once they viewed the actual details of at least the most basic of such policies.

    Among families with no unusual health burdens, the AEI plan provides pretty full insurance for four-person families with incomes below $33,000.  Things get daunting when incomes get much higher. A healthy family with an income of $67,050 would face a deductible exceeding $20,000. At the $89,000 income level, deductibles exceed $35,000, and things escalate after that.  Presumably a supplemental market would layer something on top of this. Even so…

    The authors are particularly exorcised about preventing “the forced transfer of resources from healthy poor consumers to the sick rich.”

    To advance this principle, their basic high-deductible insurance plan provides protections on a sliding scale for “extremely burdened” families predicted to experience high medical costs. The plan would impose no deductible and low copayments up to 300% of the poverty line ($67,000), and then rapidly raising the deductible when incomes reach six-figure levels. An “extremely burdened” family at 700% of the poverty line (an income of $156,450) would face a deductible of about $55,000 with 20% copayments. An “extremely burdened” family with an income of $223,500 would face a deductible of $145,000.

    I’m not sure how these extreme expected medical burdens would be calculated, how intermediate burdens would be addressed. Many details remain to be specified. Yet the underlying principle is clarifying: Low-income sick people would receive large financial subsidies. These subsidies would be dramatically reduced as one moved up the economic scale.

    Eliminating community rating

    I believe their plan’s most troubling feature is noted in one bullet point, which would overturn a central pillar of the Affordable Care Act.

    Eliminate community-rating and allow individualized premiums to eliminate adverse selection and end the forced transfer of resources from healthy poor consumers to the sick rich.

    Despite the ostensibly progressive frame, this strikes me as a gigantic blunder .

    One of ACA’s signal accomplishments was to provide an emphatic statement that prevailing practices within the individual and small-group insurance market must change. It is no longer acceptable for firms to follow a business model which relies on individual-level risk-selection through explicit or implicit discrimination against the sick, injured, chronically disabled, or others with high expected costs. Such practices expose people to unacceptable classification risk. The underwriting process also exposes people to unwarranted indignities and implicit deterrents to seeking care.

    ACA sent a clear signal to insurers—and to regulators, too—that the legal framework has changed. It will now enforce different and better social values. ACA does not impose complete community rating. Premiums are allowed to vary by age and smoking status. Beyond that, though, insurers are not to go. ACA is designed to dismantle the basic structure of medical underwriting. It rejects the idea that people should be charged higher premiums based on higher expected medical costs.

    Whether health reform can fully deliver on this promise is another matter. Community rating requires an individual mandate and  perhaps other mechanisms to ensure an adequate risk pool. Depending upon the details, young and healthy people face some incentives to “go bare” rather than to pay community-rated premiums. Ironically, community rating brings its own self-sabotage. Uninformed healthy consumers might believe—incorrectly, in the case of ACA—that they go uncovered, simply waiting to “sign up” in the event of serious injury or illness.

    Community rating can fail in the absence of such effective mechanisms. New York and other states that implemented strong community rating in the absence of individual mandates have seen serious problems. ACA’s CLASS Act sadly imploded in the absence of such mandates, too, leaving a gaping hole in the areas of disability and long-term care.

    ACA’s most immediate challenge in this area concerns allowable age-gradients in premiums. ACA already includes substantial subsidies for young and healthy people who have modest incomes. Some of these subsidies improve the risk-pool within the new exchanges. Others do not. Age-related options to purchase catastrophic coverage brings people in. Allowing young adults to remain on their parents’ insurance plans is sound policy and politically wise. Yet as Adrianna has noted, this does not help health insurance exchanges with their risk-pool difficulties.

    It might be wise to allow greater age-gradients in premiums, with implicit or explicit general revenue subsidies into the new exchanges to make these arrangements work for older people.  Allowing the system to bend in these ways is quite different from allowing insurers to individualize premiums outside the generic characteristic of age, or to legitimate a medical underwriting process that most Americans rightly consider cruel and unfair. This strikes me as a natural compromise between the ACA and what these authors are trying to accomplish. This may be  the best remedy should too few young people respond to the mandate.

    Individualized premiums reduce some incentives for cream-skimming, but create or perpetuate others. As with the ACA, any real-world insurance system modeled on the AEI plan would require (as-yet hypothesized) risk-adjustment systems, essential benefit regulations, and daunting fine-print. There is no simple and elegant solution to these inherent complexities.

    References to “the wealthy sick” occur conspicuously often in the accompanying paper. I wonder how many such people there really are, and how many dollars we’re really talking about. Particularly if one considers things in a lifecycle perspective, there are plenty of other ways for the rich to help the poor, and plenty of ways to enact more progressive fiscal policies such as raising estate taxes on the more-than-sick rich to tightening the home mortgage deduction.

    To my knowledge, no wealthy democracy implements universal coverage through this sort of individualized premium. One might ask why. Most of our peer democracies provide universal coverage at reasonable cost without undue administrative complexity within community-rated systems.

    Maybe the “healthy poor” in France, Britain, and Canada unfairly subsidize the “sick rich” in the same pathological way these authors lament. Maybe some health policy experts visited the American Enterprise Institute lamenting the regressivity of these social-democratic arrangements. If so, I missed it.

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  • Hey kids: please don’t “go bare”

    I really liked Adrianna’s last column, “Read the fine print before you burn your Obamacare card.” We had a twitter exchange about it this morning with the Cato Institute’s Michael Cannon (@mfcannon, who tweeted: “Going bare not risk-free but more rational than u suggest.”

    Michael’s a cordial guy. Let’s just say that advice to “young invincibles” about “going bare” is a singularly unfortunate metaphor for those of us working in public health, (or, for that matter, those of us who have teenage kids). More here.

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  • Picture from a “Justice for Trayvon” rally



    Feel free to add your own caption. More here–Me in the Washington Post.


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  • If you missed it the first time–Thirty economists on the individual mandate

    Thirty health economists (including some major figures–Arrow, Cutler, Gruber, Newhouse, Pollack…) wrote a letter circulated around Congress explaining the need for the individual mandate. If you haven’t seen it, I think it is one of the better one-page explanations of the issue going:

    The Patient Protection and Affordable Care Act (ACA) requires people to buy health insurance when they can afford to do so. This “individual mandate” is essential to address two features of current health insurance markets: the fact that millions of people cannot afford health insurance coverage, and the fact that insurance companies frequently charge high or unaffordable premiums to people who need insurance most-those suffering from costly illness or injury.

    This mandate is one of three pillars that together support ACA’s private market approach. The first pillar is insurance market reform – ending the ability of insurance companies to discriminate against sick or injured people with high medical costs. Subsidies to help Americans of modest means gain access to affordable health coverage provide the second pillar. The individual mandate provides the third pillar. It requires people to obtain insurance so long as that coverage is affordable. The mandate expresses a basic obligation of citizenship as well as an economic reality. Without the mandate, some people will choose to gamble or to free-ride, undermining the fairness and financial stability of the health insurance system…..

    Few of the uninsured could personally finance medical treatment for a serious illness or injury. Moreover, this country embraces the fundamental principal that everyone should have to minimally decent medical treatment when needed, without regard to ability to pay. Federal legislation and the custom and practice of health care providers embody this principle. A healthy individual’s decision to forego affordable insurance coverage thus imposes real costs on others, while raising premiums on many people with serious medical needs who require the most help….

    More here and here….

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  • HIV Testing in America’s Opioid Treatment Programs, 2005–2011…

    Our research team has performed nationally representative surveys of outpatient substance abuse treatment programs for many years. Among other things, we examine the prevalence of evidence-informed practices such as screening for HIV among program clients. More than 5,000 injection drug users become HIV-infected every year in the U.S. (some of whom are men who have sex with men, and who might have been infected via that route).

    The Centers for Disease Control and Prevention (CDC) has been pushing routine screening in substance abuse treatment centers and other providers since at least 2006. Our latest analysis, just published online in Health Services Research, shows recent trends:


    Our findings are pretty concerning. The dangers of AIDS don’t hit the front page as much as they did in the pre-HAART era. This damn thing is still with us, killing many thousands of Americans every year. Seek, test, and treat is a key strategy to reduce mortality and morbidity among those already infected, and to reduce the rate of subsequent infection by informing people living with HIV of their serostatus, and engaging these men and women into systems of care.

    The traditional network of specialty opiate addiction treatment providers had many shortcomings. The Affordable Care Act wisely aspires to link such treatment more intimately with conventional medical care. These units were, however, quite focused on HIV. As substance use patterns change, and as new players play a greater treatment role, we must ensure that HIV screening is properly addressed. Right now, we’re really not getting the job done.

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  • A personal programming note, and a comment on strong and weak ties

    Cross-posted at TIE and the Reality-based community

    I haven’t been lighting up the internets much lately. I’m away helping to care for my dad, who has kidney cancer. On Tuesday he had a radical laparoscopic nephrectomy. Amazingly, he was home the next day. He is recovering nicely. Hopefully the surgery has addressed this cancer. I’ll have more to say about this care episode and others on another occasion. For the moment, I will offer two observations.

    My dad is 84. He’s been married to my stepmother Arlene for 34 years now. He’s been semi-retired or retired for most of those years. He worked for 35 years as an engineer. Like many engineers of his generation, he made a heavy life investment in his employer. The return on this investment was to be squeezed out in the wave of mid-1980s leveraged buyouts that, in his particular case, left a broken-up company and many broken implicit contracts before the pertinent corporate raider, Paul Bilzerian, found himself in legal jeopardy.

    Although my dad definitely missed the paycheck and the dollars in his once-overvalued pension, in many ways he was happier. My stepmother was a teacher in Bergen County, New Jersey. They were fortunate to have bought their home years ago. Things worked out.

    My dad has used his time to engage very fully in the lives of my sister and me, but also the lives of my four step-sisters, and (later) their partners and children. It’s never easy to be a step-parent. Many men aren’t welcomed to really do it. Many more screw it up or don’t engage.

    That’s not my dad. He’s much more giving with his time than his friendly but work-centric son. And it shows. Read the rest of this entry »

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