JayB

I read the article a while ago - seemed like a narrative recapitulation of the data/argument at the heart of the Dartmouth Atlas. Region A spends X% more per medicare patient than region B and the outcomes are the same, ergo X% of region A's spending is wasteful. There are two major premises that underlie this argument. The first is that medicare spending is an accurate proxy for total medical spending in any given geographic area. If per-capita medicare expenditures are the same in Boulder and Biloxi, it follows that the total amount of funding that supports the health care infrastructure is going to be the same in both places, and there are no differences in total funding that might affect outcomes in either area. The second is that no variables outside of the way doctors practice medicine drive outcome-indexed medicare cost differentials between regions. All of the social, cultural, economic, geographic and other differences that distinguish Boulder from Biloxi have no real influence on outcomes. If medicare spends X dollars in a hospital treating a stroke in Boulder, then on average, spending X dollars in Biloxi should get you the same outcome. If these premises are true, then changing the way that doctors practice medicine in high cost areas will generate cost savings equal to whatever the differential between the high and low cost areas is, without affecting the quality of care. If it turns out that total spending on medical care per capita, rather than medicare spending per capita, is what drives good outcomes in the hospital, and that everything that goes on outside of the hospital before the patient arrives and after they leave has a significant effect on outcomes, then it's much less likely that simply stamping out regional variations in spending patterns will be as beneficial as both the Dartmouth Atlas and the Gawende article suggest. This isn't to say that physicians who have a financial incentive to deliver more care than is medically indicated per their best judgment don't exist, or that the additional spending that results from this behavior doesn't increase total medical spending above what it would be otherwise. These are real phenomena. Having said that, in most real cases determining the precise details of what's medically indicated is often as much a matter of opinion as a matter of fact. It's going to be immensely difficult to construct and enforce an algorithmic, centralized body of rules that attempts to make these determinations at a distance without compromising the quality of care that individual patients receive. This problem will be particularly acute for people with complicated illnesses and/or symptoms. I'm sure it's possible to develop mechanisms to minimize self-dealing by physicians, but anyone looking for a magic bullet that will contain costs without compromising the quality of care may well find themselves disappointed by the results generated by doctor-restraining methods based on statistical comparisons of spending patterns that don't take other potential sources of variation into account. Medicare Spending and Outcomes - Causation or Correlation? One of my favorites - "Why are doctors in region X using so much more oxygen than doctors in region Y for the same sorts of patients?!"

Here's a hint: Oh, and please keep repeating the same horseshit about crop yields and "feeding the poor" that agribusiness, chemical companies, and economic kooks have been telling us for the last fifty years. Last year's global food riots occurring while store shelves remained fully stocked suggests that the problem lies with the lack of food security created by the policies you've championed here rather than by lack of food. Yes - I think that we can agree that they'd be better off if global crop yields were substantially lower. You mean the crop yields of grain for livestock in another hemisphere and other mono-crops for export so they can import boxes of Krapt Mac & Cheez they can't afford when gas prices go up? Are you talking about the grotesque subsidies that the US and Europe lavish on their farmers and the way they undercut third world farmers when they're dumped on local markets? The equally pernicious effects that protectionist tariffs have on their capacity to sell the things they're good at growing and making, thereby depriving them of earnings that they could exchange for food? Both?

When I see dudes wandering around in Bunny Suits in the strawberry fields because the chemicals can kill them, successful lawsuits about chemical contamination from field runoff, and other nastiness my first thought isn't "this shit sounds good to eat" you sound like a creationist JayB I agree. There's no relationship between dose and toxicity.You should employ the same logic with all chemicals. Pharmaceuticals, ethanol, you name it.

Here's a hint: Oh, and please keep repeating the same horseshit about crop yields and "feeding the poor" that agribusiness, chemical companies, and economic kooks have been telling us for the last fifty years. Last year's global food riots occurring while store shelves remained fully stocked suggests that the problem lies with the lack of food security created by the policies you've championed here rather than by lack of food. Yes - I think that we can agree that they'd be better off if global crop yields were substantially lower.

Hey Bill: I think that those are related, but separable questions, and it's reasonable to consider them separately and ask whether or not there's evidence to support each of the specific claims made on behalf of organic foods. Consequently I think it's fair to conclude that anyone who claims that organic foods are more nutritious is making a claim that's at odds with the best evidence available to us at this point. It certainly may be true that people are concerned about exposure to pesticides, hormones, and antibiotics in non-organic food. Are their concerns sincere? I'm sure that they are, but it's fair to ask whether the concerns that you mentioned have their basis in a scientific consensus or not. There isn't - at least as far as I'm aware - any scientific consensus that supports the claim that eating food produced via conventional methods exposes people to any measurable health risks vis-a-vis organic foods. Nor is there any evidence that supports the claim that if the same people ate organic food exclusively they'd be any healthier or live any longer. It's also not clear to me that there's a bright red line that delineates all organic methods from all conventional methods, nor is it clear that the bits of agriculture that does fall one one side of the line or the other can be objectively classified as good or bad, beneficial or harmful. I think that there's a pretty clear consensus of opinion that starvation is bad, habitat destruction to increase cropland is bad, increasing water pollution is bad, etc, etc, etc - but most of the time we're confronted with a series of trade-offs and value judgments that make determining what's best extremely problematic and highly dependent on the all of the conditions and variables at play in a particular context. I'm generally of the opinion that starvation and malnutrition are objectively bad and that their effects on health are substantially more severe than any adverse effects that hormones, antibiotics, and pesticides might have. I'm also of the opinion that that the social effects of starvation and malnutrition can lead to effects on the environment that are many times worse than the cumulative effects of hormones, antibiotics, fertilizers, and pesticides. I'm glad that well-fed people in prosperous countries can buy food that's consistent with whatever value system they want to employ, whether there's any scientific evidence to support all or part of their motives for doing so, but I'd hate to see them impose the same constraints on other people who aren't as well-fed.

My goodness - quite the impassioned response to a fairly simple article. The study referenced in the article was only considering nutrition. I've often heard people claim that one of the primary motives for eating organic food was that it's better for you. Apparently they've all been disingenuous! Good to know. If there's a study out there that's equally rigorous and comprehensive study out there that the nutritional value of organically produced food is higher, I hope that you'll share that study here - and then forward it to the media, post haste. There may or may not be other benefits to cultivating food using methods that fall under some definition of "Organic" (Is there a standard definition of what this means yet?). Depending on how you define organic food production, it may or may not satisfy a particular definition of "sustainability." If any of the definitions of sustainable includes "capable of growing enough food to feed everyone now and for the next 40 years" then maybe not. Ditto for whatever other criteria may or may not be part of someone's particular definition of sustainability (If there's a consensus definition that I'm not aware of here, as per organic, please share it). It'd be interesting to compare current and projected yields per acre for conventional vs some fixed definition of organic cultivation and see what the data suggest. But hey - at the end of the day - I'm in favor of everyone being able to grow and/or consume food that's consistent with pretty much whatever value system that they want to incorporate into the process. If you want peaches harvested under a full moon by a troupe of Bolivian clowns in lederhosen, and are willing to pay whatever premium is necessary to get them to your fridge - more power to you. You're free to do that, and I'm free to question any factual claims that you wish to advance about the benefits of doing so.

Yea - looks like Canada has lower administrative costs than the US does. Ergo - what, exactly?

Yup. http://www.vhemt.org/

"Organic 'has no health benefits' Organic food is no healthier than ordinary food, a large independent review has concluded. There is little difference in nutritional value and no evidence of any extra health benefits from eating organic produce, UK researchers found. The Food Standards Agency who commissioned the report said the findings would help people make an "informed choice". But the Soil Association criticised the study and called for better research. Researchers from the London School of Hygiene and Tropical Medicine looked at all the evidence on nutrition and health benefits from the past 50 years. “ Without large-scale, longitudinal research it is difficult to come to far-reaching clear conclusions on this, which was acknowledged by the authors of the FSA review ” Peter Melchett, Soil Association Among the 55 of 162 studies that were included in the final analysis, there were a small number of differences in nutrition between organic and conventionally produced food but not large enough to be of any public health relevance, said study leader Dr Alan Dangour. Overall the report, which is published in the American Journal of Clinical Nutrition, found no differences in most nutrients in organically or conventionally grown crops, including in vitamin C, calcium, and iron. The same was true for studies looking at meat, dairy and eggs. Differences that were detected, for example in levels of nitrogen and phosphorus, were most likely to be due to differences in fertilizer use and ripeness at harvest and are unlikely to provide any health benefit, the report concluded. The review did not look at pesticides or the environmental impact of different farming practices. Gill Fine, FSA director of consumer choice and dietary health, said: "Ensuring people have accurate information is absolutely essential in allowing us all to make informed choices about the food we eat. "This study does not mean that people should not eat organic food. "What it shows is that there is little, if any, nutritional difference between organic and conventionally produced food and that there is no evidence of additional health benefits from eating organic food." She added that the FSA was neither pro nor anti organic food and recognised there were many reasons why people choose to eat organic, including animal welfare or environmental concerns. “ Organic food is just another scam to grab more money from us ” Ishkandar, London Dr Dangour, said: "Our review indicates that there is currently no evidence to support the selection of organically over conventionally produced foods on the basis of nutritional superiority." He added that better quality studies were needed. Peter Melchett, policy director at the Soil Association said they were disappointed with the conclusions. "The review rejected almost all of the existing studies of comparisons between organic and non-organic nutritional differences. "Although the researchers say that the differences between organic and non-organic food are not 'important', due to the relatively few studies, they report in their analysis that there are higher levels of beneficial nutrients in organic compared to non-organic foods. "Without large-scale, longitudinal research it is difficult to come to far-reaching clear conclusions on this, which was acknowledged by the authors of the FSA review. "Also, there is not sufficient research on the long-term effects of pesticides on human health," he added." They also neglected to account for the health benefits derived from the psychic rewards that consumers derive from purchasing this sub-set of positional goods. http://news.bbc.co.uk/2/hi/health/8174482.stm

If true, does this figure including the time private companies must spend filing government paperwork etc etc? Doesn't account for the cost of generating revenues via the IRS, [...] Rightwing spin isn't supported by the evidence (some of it is nonsensical because most healthcare dollars are already paid by taxes): "These administrative spending numbers have been challenged on the grounds that they exclude some aspects of Medicare’s administrative costs, such as the expenses of collecting Medicare premiums and payroll taxes, and because Medicare’s larger average claims because of its older enrollees make its administrative costs look smaller relative to private plan costs than they really are. However,the Congressional Budget Office (CBO) has found that administrative costs under the public Medicare plan are less than 2 percent of expenditures, compared with approximately 11 percent of spending by private plans under Medicare Advantage.16 This is a near perfect “apples to apples” comparison of administrative costs, because the public Medicare plan and Medicare Advantage plans are operating under similar rules and treating the same population. (And even these numbers may unduly favor private plans: A recent General Accounting Office report found that in 2006 Medicare Advantage plans spent 83.3 percent of their revenue on medical expenses, with 10.1 percent going to non-medical expenses and 6.6 percent to profits—a 16.7 percent administrative share.)" http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.pdf "My basic point was that expressing health administrative costs as a percentage of total program costs is silly, since the bulk of program costs are health care claims and administrative costs are mostly unrelated to the level of health care claims. (Medicare claims processing is only about 4% of administrative costs; the other 96% is unrelated to the level of claims). This is clear from a moment’s thought — if you insure a healthy 25-year-old who never goes to the doctor (or at least, not enough to exceed the deductible), a health plan’s cost for that person is 100%, no matter how efficient the administration is. Private insurance has a lot more people like that than Medicare does. The appropriate measure is administrative cost per person, and by that standard Medicare is more expensive than private health plans. This point stands unrefuted, even with the additional quote from Jacob Hacker. Hacker refers to a GAO report that says administrative costs (including profit) for Medicare Advantage plans (privately-run managed care plans for Medicare beneficiaries) total 16.7% of total program costs. Hacker claims that “This is a near perfect `apples to apples’ comparison of administrative costs, because the public Medicare plan and Medicare Advantage plans are operating under similar rules and treating the same population.” This is simply not true. The Medicare Payment Advisory Commission (MedPAC) reports (page 62) that Medicare beneficiaries who report their health status as “excellent” or “very good” are twice as likely to enroll in Medicare Advantage as those who report their health status as “poor.” Any Medicare beneficiary can enroll in Medicare Advantage, but those who choose to do so are, on average, healthier than those who remain in the “traditional” Medicare program. In short, Medicare Advantage plans are not “treating the same population.” They are not “operating under similar rules” either; the Medicare Advantage plans have an entire set of regulations of their own, quite different from the rules of the traditional Medicare fee-for-service system. Putting aside the factual errors and the fact that expressing administrative costs as a percentage of total costs is misleading, the GAO report doesn’t say what Hacker says it says. The administrative costs shown in the GAO report include major administrative functions not included in the figures are not comparable to those for reported by Hacker for the traditional Medicare. Since the bulk of Medicare Advantage plans are HMO plans, the 16.7% figure includes both functions of operating a health plan and functions that occur in doctors’ offices and health plans. In traditional Medicare, the fees paid to physicians and hospitals include an amount attributable to their internal administrative costs. For physicians, that amount averages 17.3% of their fees — this is administrative costs in addition to costs incurred at the Medicare program level, which Hacker says is 2% but is actually 3% or 6%, depending on whether you include just the cost of the Medicare bureaucracy, or that plus other the cost other government agencies incur in support of Medicare. So even if we believe Hacker’s comparisons between Medicare Advantage and traditional Medicare, a true “apples-to-apples” comparison shows that traditional Medicare’s administrative cost are higher — even using a “percentage-of-costs” approach weighted in its favor." Even if a methodologically sound accounting of all of Medicare's administrative costs are lower, which hasn't been done, that would do nothing to advance the larger claim that lower administrative costs necessarily translate into more efficient use of resources or better value for money. Much less that a centrally administered rationing and price-fixing scheme will do a better job of coordinating supply and demand, fostering new efficiencies through innovation, etc. Now that we've covered administrative costs, life-expectancy, and infant mortality - I hope that someone will dredge up the "X number of people are dying each year because they lack insurance" canard. Nothing makes more sense than taking demographic cohorts with vast differences in income, employment, education level, fitness, marital status, alchohol/tobacco consumption et...cetera and chalking the net differences in mortality up to a single variable.

1. Does it necessarily follow that establishing a public plan is the optimal remedy for this problem? E.g. - instead of simply drafting legislation to minimize or eliminate it? 2. What evidence do you have to support the claim that severity and urgency will be the sole criteria by which a public plan allocates scarce resources with many alternative uses? Is this a statement of fact, or an article of faith?

If true, does this figure including the time private companies must spend filing government paperwork etc etc? Doesn't account for the cost of generating revenues via the IRS, doesn't include the costs of government employees in other agencies that are involved in administering Medicare, doesn't include the costs of capital reserves that private insurers are required to hold in order to meet statutory requirements for capital adequacy, doesn't include taxes that private insurers have to pay, the fact that overhead as a percentage of claims is affected by the average size of the claim, and I'm sure that there are others that I'm forgetting. If private insurers got all of their money for free from the government, didn't have to pay any taxes, spent next to nothing on claims revue and fraud prevention, and contracted out the task satisfying claims to the outside vendor with the low bid, etc - then the Medicare vs private insurer comparison would be meaningful. It's also worth examining whether or not a reduction in a given enterprises' profits will necessarily translate into proportionate benefits for consumers. GM, for example, has done a phenomenal job of eradicating profits in the past three years, but it's worth asking if consumers have enjoyed either increases in quality or reductions in price that are commensurate with the magnitude of GM's lost profits plus outright losses.

I can't offer any insight relative to the Gunks, but if climbs at a given grade there really are that much more difficult than climbs pretty much everywhere else, then when it comes to alpine routes in the Cascades, there are probably special cases where you could systematically downgrade the technical rating by the factor that you have proposed and have a relatively low probability of finding yourself hopelessly out of your depth as a result. In my mind, those cases would be most heavily trafficked trade-routes, that have been getting climbed dozens of times every season, by folks from around the country, and which have been more or less continuously re-evaluated and perhaps re-graded for the past thirty years or so, and for which it's possible to get something close to move-by-move micro-beta. In prime summer conditions. Apply that same method to remote routes that are seldom repeated, have rock of indeterminate quality, and for which the prime reference is a short entry in one of the Beckey volumes and the probability that the applying the "Gunks Veteran Auto-Downgrade" (GVAD) will result in an experience that's profoundly humbling, at best, becomes dramatically higher. I don't know from experience, but I suspect that applying the GVAD to routes that include the name "Doorish" in the FA citation, as well as some other key surnames*, is particularly likely to result in an experience that'll be as unfortunate as it will be memorable. That's in perfect weather. Not sure that answers your question in full, but I hope you find it helpful. *Maybe some folks will chime in with other helpful suggestions concerning FA surnames, routes, and/or mountains/ranges that are best avoided when employing the GVAD.

Good photographic and scientific overview of glacial retreat in the North Cascades here: http://www.nichols.edu/departments/glacier/Bill.htm

Flood damage repaired up to the Taylor River Bridge, which has been washed out. Reports indicate extensive damage between this point and the Dingford Creek trailhead. Anyone have any idea if repairing the bridge and the damage beyond it is on the agenda any time soon? There's a million-dollar footbridge up at Dingford that won't be seeing much traffic unless vehicle access is restored.....

Hey Brian: I'm very sorry for all of the pain, sorrow, and grief that you and your family have had to endure in the years transpired between the onset of the disease and your wife's passing. I hope family, friends, and all of the other sources of comfort and happiness that life affords eased the hardship that your family endured during her illness, and provide you with ongoing comfort after her death.

Spare me your usual crapola JayB. Who decides that greenhouse gas emissions should be reduced? Who decides that PCB, asbestos, … should be used only in a very controlled environment? Who decides that the content of cigarettes should be carefully monitored? Who decides that plywood, sheetrock, foams shouldn’t de-gass noxious chemicals in our living and working spaces? Etc … You see, the regulatory agencies, the experts already exist and make decisions all the time so there is no need to present yourself as the perpetual defender of freedom when, in fact, you act as a defender of the right of corporations to run our lives with as little regulation as possible so that they can maximize profits at our expense. What does any of the above have to do with outlawing risky behaviors where the adverse consequences are limited to the sane adults who willingly engage them on their own or with other consenting adults? Regulations that specify a set of standards that a given industry, profession, etc have to abide by are something else entirely, kemosabe.

Quite the circular non-explanation there. Poverty and war cause...poverty and war. Ending agricultural subsidies and eliminating tariffs that make it next to impossible for them to sell the stuff that they're good at growing - whether that turns out to be GMO crops or organic, GMO-free dreadlock-delousing paste - in the markets where they can secure the highest prices for them would be much more helpful than a set of cloistered first-world activists trying to make these choices for them. jeez jay! didn't you get the memo? do you really still think the free market economy is the cure for everything? If I had a nickel for every Asian that wishes they'd relied on foreign aid and central planning instead of trade so that they could live like Africans...I'd be a wealthy man. Hopefully the Asians will see the light one of these days and finally start copying the economic policies that Africa's relied on to get where it's at today.

plus they don't have the $ to buy a tv. one wonders how Africans ever survived before the world economy. they must have been in continual subsistence starvation, which I guess is different than actual starvation. It's strange that they aren't clamoring to return to lifestyles they had in the good old hunter-gatherer days when life was much easier and food was always secure and plentiful. They must not understand how good they had it back then.

Quite the circular non-explanation there. Poverty and war cause...poverty and war. Ending agricultural subsidies and eliminating tariffs that make it next to impossible for them to sell the stuff that they're good at growing - whether that turns out to be GMO crops or organic, GMO-free dreadlock-delousing paste - in the markets where they can secure the highest prices for them would be much more helpful than a set of cloistered first-world activists trying to make these choices for them.

It's funny, except it's not true. People in Africa are not starving because they are somehow incapable of growing their own food, or because the land is recently unfit for agriculture. It's a policy problem of how their governments are run. They are kept in extreme poverty by warlord dictators, by Western trade policies that force them to grow cash crops rather than their own food and then prevent them from making a sustainable amount of money doing so (see: coffee, cacao), and by their constant refugee status as inter-tribal wars force them to flee from their homes. Besides which, if Africa is so impoverished, why would the solution be highly a commercialized agriculture program where the company (Monsanto, etc.) owns the "rights" to the cultivars, and requires that farmers 1) pay a lot for the specialty seeds, 2) pay a lot more for the required pesticides/whatever, and 3) buy new seeds every year, because it is illegal to save seeds from the plants they've grown? People in Africa are starving because they can't generate sufficient net output to exchange for the money or goods necessary to lift themselves above subsistence poverty. The people of Taiwan, for example, manage to eat just fine, despite the fact that virtually none of their output is composed of edible foodstuffs. Ditto for the folks in Singapore. They get their food the same way that we get our flat-screen TV's - despite the fact that virtually none are produced here. This happens as a result of the same mechanism that you use to feed yourself, despite the fact that you don't have a cattle ranching operation, acres of corn, rice, beans, a brewery, a cannery, a dairy, etc in you backyard. You sell what you do produce for cash, then exchange the cash for all of the things that you can't make yourself. The solution for Africa would be to concentrate on exploiting whatever comparative advantages they have that generate the most net income for them, and using the proceeds to buy everything else. That might be anything from whisking busloads of elderly westerners past a pack of hyenas in an air-conditioned bus, to assembling widgets, to monetizing the guilt of first-world activists by selling them overpriced trinkets in Bono endorsed kiosks next to the Hot Topic store at the mall...to highly mechanized, fossil-fuel intensive production of GMO crops. Completely depends on an infinite variety of local circumstances that are constantly changing and can't be known, much less understood and effectively harnessed by any centralized authority. This fundamental oversight, when combined with tariff and subsidy laden trade and agricultural policies that make it next to next to impossible for the folks in Africa to compete even in the agricultural/industrial arenas where they do have an advantage over the rest of the world. Layer political models that concentrate economic and political power in a centralized government that change the stakes of political change from tending to the business of the state to personally commanding all of the resources in the state on top of everything else and voila...Hobbesian nightmare of staggering proportions. Toss in massive amounts of fungible aid that can be easily confiscated and re-sold if you want to really get the downward spiral swirling.

A comforting mythology for you to be sure. Reality is rather more complicated though: Complicated. Hmmm - yes. The "march, chant, confiscate, nationalize, eliminate competition and trade" development model has certainly complicated the lives of folks who have embraced it or had it imposed on them. Which one's your favorite at the moment? Mine's Zimbabwe.

Ha! As if the global poor are neither capable of or haven't been articulating their own resistances to capitalist globalization in every corner of the planet. Where have you been for the last ten years? Speaking of "Resistance"... Gets better every time....

From 'The New Republic'...tee hee... "Green had moved beyond politics. Gestures that were once mundane--bringing your own grocery bags to the store, shopping for secondhand clothes, taking the subway--were suddenly infused with grand significance. Actions like screwing in light bulbs, inflating tires, and weatherizing windows gained fresh urgency. A new generation of urban hipsters, led by Colin Beavan, a charismatic writer in Manhattan who had branded himself "No Impact Man," proselytized the virtues of downscaling--dumpster-diving, thrift-store shopping, and trading in one's beater car for a beater bike--while suburban matrons proudly clutched copies of Michael Pollan's In Defense of Food and came to see the purchase of each $4 heirloom tomato at the farmer's market as an act of virtue.... Of course, environmentalism itself has not disappeared. Earth Day was celebrated last week, magazines and marketers continue to use green to sell to upscale audiences, and legislation to cap carbon emissions, albeit heavily watered-down, could still pass Congress. But the cultural moment marked by the ubiquity of green self-help, apocalypse talk, and cheery utopianism has passed. It is tempting to reduce this retrenchment to economic pressures alone, with concrete short-term concerns trumping more abstract worries about the future. But a closer look at the causes of the green bubble reveals a more complicated story, not just about the nature of environmentalism but about modern American life itself. At the same time that liberal professionals were feeling estranged politically, they were also feeling alienated personally and socially. For perhaps the first time in history, according to New York University sociologist Dalton Conley's new book, Elsewhere, U.S.A., American elites were working longer hours than the poor. They were making more money, but the price they paid was longer commutes, the commodification of everything (from private schools to bottled water), and less time for themselves, their families, and their friends. Inequality skyrocketed during the 1990s, resulting both in new affluence for the wealthiest 20 percent and in heightened social anxiety. In these conditions, upper-middle-class liberals started questioning and resenting hyper-materialism, even while enjoying the status and comfort it offered. Little surprise, then, that they would start buying a whole new class of products to demonstrate their ecological concern. Green consumption became what sociologists call "positional consumption"--consumption that distinguishes one as elite--and few things were more ecopositional than the Toyota Prius, whose advantage over other hybrid cars was its distinctive look. A 2007 survey that appeared in The New York Times found that more Prius owners (57 percent) said they bought the car because it "makes a statement about me" than because of its better gas mileage (36 percent), lower emissions (25 percent), or new technology (7 percent). Prius owners, the Times concluded, "want everyone to know they are driving a hybrid." The status effects were so powerful that, by early 2009, Honda's new Insight Hybrid had been reshaped to look like the triangular Prius. Of course, for many greens, healing required more than a new kind of consumption, however virtuous. In The New York Times Magazine's 2008 Earth Day issue, Michael Pollan argued that climate change was at bottom a crisis of lifestyle and personal character--"the sum of countless little everyday choices"--and suggested that individual actions, such as planting backyard gardens, might ultimately be more important than government action to repair the environment. Pollan half-acknowledged that growing produce in your backyard was ecologically irrelevant, but "there are sweeter reasons to plant that garden," he wrote. "[Y]ou will have begun to heal the split between what you think and what you do, to commingle your identities as consumer and producer and citizen." ...It's easy enough to point out the insignificance of planting a garden, buying fewer clothes, or using fluorescent bulbs. After all, we can't escape the fact that we depend on an infrastructure--roads, buildings, sewage systems, power plants, electrical grids, etc.--that requires huge quantities of fossil fuels. But the ecological irrelevance of these practices was beside the point. What downscalers offered was not a better way to reduce emissions, but rather, a way to reduce guilt. In 2007, we asked environmentalists in focus groups about green consumption. None thought that consuming green would do much of anything to address a huge challenge like global warming. They did it anyway, they said, because it made them feel better. ...Against nostalgic accounts like Howard Zinn's A People's History of the United States, most social-change movements are started and directed by the relatively affluent and well-educated, from the preacher-led civil rights movement to modern feminism to gay rights. The problem is not that most greens are elites, per se, but rather that too few of them acknowledge the material basis for their ecological concern and that too many reject the modern project of expanding prosperity altogether... There are, to be sure, negative and disorienting aspects of modern life: pollution, alienation, loneliness, inequality, and the proliferation of choices. But the truth is that, while we often talk of our desire for greater community and interconnectedness, we choose ever more privacy, autonomy, and personal freedom. Few of even the most ardent greens could seriously imagine subsuming their individual identities to a pre-agrarian tribe, or abandoning their office jobs for a life of hard agricultural labor. The retreat from older forms of community, and the move toward greater individuation, is universal and largely positive. Colin Beavan and Michael Pollan lament, respectively, the loss of community and the loss of connection between humans and the land. But both choose to live alone with their families in cities, not on agricultural communes, and both express themselves as unique thinkers and writers. Nonetheless, it has become an article of faith among many greens that the global poor are happier with less and must be shielded from the horrors of overconsumption and economic development--never mind the realities of infant mortality, treatable disease, short life expectancies, and grinding agrarian poverty. The convenient and ancient view among elites that the poor are actually spiritually rich, and the exaggeration of insignificant gestures like recycling and buying new lightbulbs, are both motivated by the cognitive dissonance created by simultaneously believing that not all seven billion humans on earth can "live like we live" and, consciously or unconsciously, knowing that we are unwilling to give up our high standard of living. This is the split "between what you think and what you do" to which Pollan refers, and it should, perhaps, come as no surprise that so many educated liberals, living at the upper end of a social hierarchy that was becoming ever more stratified, should find the remedies that Pollan and Beavan offer so compelling. But, while planting a backyard garden may help heal the eco-anxieties of affluent greens, it will do little to heal the planet or resolve the larger social contradictions that it purports to address...."

you might be mistaken about "catastrophic insurance" policies, or you have looked at policies which i am unfamiliar with. most of these policies i am familiar with have a high deductible, a certain percentage copay for hospital visits or other procedures, with a cap on maximum out-of-pocket costs for policy holder (always(?) under 10 grand). correct me if i'm wrong. $186/month gets two of us 5k deductible, 20% copay thereafter, 10K maximum out of pocket per-year, two million lifetime coverage. Our primary goal is to limit the maximum costs of a medical catastrophe, not enroll in a pre-paid monthly plan that costs considerably more than the health care that we're actually likely to use in anything less than a catastrophe. Ergo it might not be for everyone, but it looked like the coverage that made the most since for us.