I have been plagued with a cough for what seems like a week but has only actually been a few days. It started Friday and then got progressively worse really quickly. I am not generally big on medications, but I have taken everything my wife has thrown at me. At first it was just a throat discomfort. There were kind of rotating symptoms. I wasn’t hungry and then I couldn’t talk (but could eat) and then was coughing up a lung (wanting to eat and talk but being scared to). The coughing outlasted the rest and it’s been a persistent problem then.

There have been mild improvements. It’s extremely frustrating because I will be perfectly fine for hours and then suddenly I just can’t stop coughing. I’m not getting enough sleep because I start coughing most when I lay down and when my coughing muscles are too exhausted and I fall asleep I wake up after four hours coughing my brains out. Insult to injury, I can’t even yawn because it stretches my throat forcing me to, you guessed it, cough.

Question: Are doctors in the United States overpaid?

Answer: If we judge by how well compensated doctors in foreign countries are paid, the answer is an affirmative. There are a couple of caveats to this, however. For one thing, being a doctor in the United States is often a more expensive proposition than abroad. In many countries, doctors do not have to spend a full eight years in school (and incur the costs thereof) and higher education has greater subsidization by the state. By the time a doctor finished a three-year residency at 29 years of age or older (excluding prodigies), they have made maybe $150k in salary as a resident and may be in debt anywhere from $150k-500k. Had the same student chosen a business, engineering, or technical field, they could easily have earned in excess of $300k and will owe only what they paid for their undergraduate education.

All of that being said, even if you factor these things in, our physicians are still very well paid and from a financial standpoint will be better off for having chosen to be a doctor. I mention the caveats because they will come up later.

Q: Is this because of an artificial shortage of physicians created by the medical establishment?

A: The evidence for this is pretty weak. Back in the early 1980’s and 90’s there were fears within the medical community of an excess of doctors. They severely reined in the number of slots at medical schools and the creation of more medical schools. Thus, the physician shortage was either born or at least exacerbated. The result? Physician compensation since the early 90’s has been stagnant. Between 1995 and 2003, it actually fell 7%. A good portion of that fall can be ascribed to the average number of weekly hours a doctor works falling from the mid 50’s to the low 50’s, though even if you factor that in you still have stagnation.

Further, if shortages drew up compensation, you would see differences in how much specialties have changed over time. Primary care physicians are in particularly short supply, but it has not resulted in an increase in compensation. If anything, their wages have been the most constant and consistently below specialties where the shortages are not occurring or at least not occurring as loudly.

Q: What about supply and demand?

A: They don’t seem to apply as much to physicians as you might think. There are a lot of reasons for this, which will be explored below. The long and short of it is that physicians don’t work in a traditional market economy. Their ability to fully take advantage of their scarcity is limited by the fact that they have to negotiate with insurance companies and the government who contain a large amount of bargaining power. Rural hospitals, for example, have a really difficult time recruiting. Doctors often don’t want to live in the sticks and the ability of a hospital to bribe them to do so is limited by a relatively inflexible payment structure.

That’s not to say that the industry is immune from market forces. If we’d been adding thousands upon thousands of doctors since the 90’s, it’s possible that pay would have gone down more than it did because it would have given insurance companies and the government additional negotiating leverage. However, as I will explain below, that would not necessarily lower the collective costs of health care. Even if they didn’t, more doctors would increase access to care, though, and that is a worthwhile goal in its own right. Nothing I write here should be construed as a desire for the perpetuation of the physician shortage.

Q: So are physician salaries responsible for the skyrocketing costs of health care in this country?

A: Not in the direct way that a lot of people imagine. As explained above, the increased money flowing into the system has not been making its way into the hands of physicians. As I will explain below, without other changes you’re not going to see significant savings when the bill comes due.

Q: Still, though, we could reduce costs if we paid physicians less. Right?

A: Right, though not as much as you might think. According to health care economist Uwe Reinhardt, Physician take-home pay is about 10% of total health care expenditures. If you cut that in half, you have saved 5% of health care expenditures. That’s an aggressive estimate. Some people cite a the McKinsey Global Institute figure of $64 billion that we spend on higher earnings for physicians. Two noteworthy things about the MGI numbers. First, they cite “physician compensation” as being rougly 8.7% of health care expenditures instead of 10%. Second, while $64b is a large number, eliminating it would only represent a savings of 3% of total health care spending.

However, in order to make those cuts we would probably need to do one of three things: We would either need to reduce the costs of becoming a doctor, we would need to resign ourselves importing our doctors, or we would have to accept medicine as a less desirable profession that the best and brightest are not going to be interested in..

In the case of reducing the costs to become a doctor, there are ways we could do that which wouldn’t be expensive. For instance, we could scratch the requirement that doctors get an undergraduate degree. That way they could go straight into medical school and get out in fewer than 8 or 9 years. Other solutions, though, would involve subsidizing their education and that would cost money. Right now it’s not unfair to expect doctors to incur all manner of debt to become doctors because after they do they will be compensated enough to pay them back. Take away the compensation and you take away the willingness of the best and brightest top become doctors. If you’re thinking that we can count on them doing it for the job satisfaction, think again.

We could still import foreign doctors. Keep in mind, though, that the foreign doctors we would be importing would not be be coming from Europe and England. Since we wouldn’t be pay much more over here than they do over there, they would have no reason to come here. Instead, we would be getting doctors from India, Latin America, underdeveloped East Asia, and Africa. To be fair, I can’t remember the last time I saw an eye doctor without a thick accent and I have been very satisfied with the service that I have gotten from them, so it’s not something I am personally deeply afraid of. But it’s just something to keep in mind. A lot of people feel differently.

Q: Still, though, we could reduce costs if we paid physicians less. Right?

A: Yes, if we are willing to cut physician wages, if we still let them fend for themselves when it comes to getting their medical education, if accept that an undetermined number of those among the best and the brightest that become doctors now would instead do something else, if we are willing to see an increasing number of doctors from the third world, and if we are willing to risk losing American-educated doctors to Canada, we could save 3-6% of our health care costs.

Oh, and if we’re able to figure out a way to reduce physician pay. Reducing reimbursements and fees alone is not only unlikely to accomplish this, but could backfire and cost us more money. A lot of it. I mention above that health care costs are skyrocketing while physician pay has been stagnant. Arguably, these two are related. As costs have gone up and reimbursements have not, many doctors have chosen to get… creative. Entrepreneurial, even.

Let’s consider a fictitious doctor named Dr. Arthur Pineur. Dr. Pineur gets $70 every time he runs Test X, which costs him $50 to run and he does twice a week costing insurers and the government $140 and netting him $40. If you cut his reimbursement to $60, he can either accept the slashed pay or he can make up for it somehow. If Pineur is not a particularly ethical man, he can just target random patients and run the test twice as much. He used to run it twice a week, now he runs it four. He is making the same $40 he was making before, however the system is now paying $240.

A year or so passes and expenses have gone up but reimbursements have not. How can he avoid taking an income hit? Well, he can order Machine Y so that he can run Test Y. That way, he can profit every time Test Y is run. So he puts down $10,000 and buys Machine Y. Okay, well now he has to justify that investment and pay back the loan he took out to buy it. So now he’s running Test X and Test Y as often as he can. The more he is squeezed, the more ways he finds to supplement his income.

Now, Dr. Pineur has an ethical shortcoming. But there are a lot of gray areas that he is exploiting, so he’s not committing out-and-out fraud. In fact, maybe he can even convince himself that he is doing the right thing because he’s just giving his patients the most care that he can. The more docs do this, the more he can justify it to himself. Before long, you have a medical culture built around it. You have McAllen, Texas.

Now, McAllen is an extreme example, but at the end of the day at present it is not the job of doctors to control costs. Throw in litigation concerns, doctors earnestly wanting to try to treat and screen for everything just in case, and incentives to inflate costs and they can (sometimes intentionally, sometimes unintentionally) generate a whole lot of costs even while ultimately taking home comparatively little of it. Racking up a quarter’s worth of cost for a nickel’s profit.

If you’re looking at doctor pay and the high cost of health care in this country, you’d do a lot better looking at the “how” rather than the “how much” doctors are paid. Of course, that’s easier said that done. Most available options involve some list of things undesirable to many or most Americans. The potential savings from that, however, are much more significant.

-{Disclaimer: Do I really need to even say so? Well, I will for new readers. My wife is a doctor. She is a doctor in one of the least profitable sectors of medicine (because she chose to be, not because she didn’t have options). She is a salaried employee, so my Dr. Pineur example should not be considered commentary on how she practices medicine. She did not contribute to the writing of this post.}-

Trumwill: Formatting and restoring is like going to the dentist. It’s something you should probably do every six months or so, but it’s really inconvenient and not very fun, so most people - myself included - put it off until the last possible moment.

TrumDad: Speaking of dentists…

Trumwill: I knew I shouldn’t have used that metaphor!

TrumDad: How long have you had that cavity?

Trumwill: Six months, possibly a year.

TrumMom: And when do you plan on doing something about it?

Trumwill: Well, the way I see it I don’t know when Arapaho licensure is going to go through and when her insurance is going to kick in, so that could be a problem.

TrumDad: How?

Trumwill: Well, let’s say that I visit a dentist who determines that I have a cavity. Then, by the time it’s time to get that cavity filled, I’m on her insurance. But they don’t have a record of the first visit. Or it becomes a pre-existing condition.

TrumDad: Or I have a better idea. Why don’t you call tomorrow morning, explain the situation, and make two appointments. Find out if any of the dentists in Callie can do that.

TrumMom: I like your father’s idea.

Trumwill: Yeah… but… you see… that’s… uhm…. how many extra calls? Or I can wait for a couple months and visit then.

TrumParents: {Forcefully failing to buy it}

Trumwill: Dad’s pressuring me to go to the dentist.

Clancy: Didn’t you say you had a cavity?

Trumwill: Well, let’s say that I visit a dentist who determines that I have a cavity. Then, by the time it’s time to get that cavity filled, I’m on her insurance. But they don’t have a record of the first visit. Or it becomes a pre-existing condition.

Clancy: I’m sure if you explained it to a dentist they would see what they can do to get the two appointments before the insurance change. Why not at least call and find out?

Trumwill: That’s exactly what Dad said!

Clancy: … and?

Trumwill: And y’all are throwing monkey-wrenches into my logic here.

Clancy: I’m looking around and I’m not seeing any logic here.

Trumwill: Stop that! You’re ruining my plan!

Clancy: I’m looking around and I’m not seeing any plan - any real plan here.

Trumwill: It’s hiding. My plan is a shy one.

There are three main health care-related insurance types out there that I am familiar with (excluding disability or life insurance, which are health-related but not health care-related): Health, dental, and vision.

The benefits of health insurance are pretty straightforward. People never know when or if they’re going to get hit with some massive health problem that is going to cost more money than they have. So you join a risk pool to mitigate the consequences of whatever occurs. Even if you stay healthy, you at least theoretically have the comfort of knowing that you will be taken care of if you have a heart attack. And if you don’t stay healthy, you don’t have to worry as much about paying for everything out of pocket. Of course, modern health insurance goes above and beyond that, but whether these changes have been good or not, the basic concept is still there.

Dental insurance is similar, although the stakes and premiums are smaller. You’re not generally going to get hit with anything enormously expensive, but there are some things that it’s difficult to account for and getting hit with a multi-thousand dollar bill at the wrong time can be pretty dreadful. I am inclined to think that dental insurance is not a particularly good idea if you have the kind of savings that you can pay for root canals and the like out of pocket, but a lot of people can’t. And even when my wife and I get to the point where we can we can pay out of pocket for anything that comes up I will still want the insurance because it encourages me to go to the dentist more often.

But vision insurance is a real puzzler. People either need vision care or they do not. Then, once they need it, the expenses are pretty regular. Vision check once every year or so. One new pair of glasses every few years. Contacts every six months. The thing is, though, that all of these expenses are relatively minor and they’re scalable to whatever the family needs. Nobody needs an emergency prescription update. If you can’t afford contacts, you can just get glasses. You can get glasses easily for under a couple hundred bucks or you can spend more if you have more money. Unlike health insurance or dental insurance, you’re not going to be hit with bills in the thousands of dollars.

In the event that something bad with your eyes does happen and it’s the sort of thing that is expensive, it’s typically handled by health insurance. My suspected glaucoma was a health insurance matter as was all of the testing as to whether or not I had it. As far as I know, that’s how it generally works.

I genuinely do not understand why vision insurance exists.

I mean, I know why each of the actors play the part that they do. For employers, it’s one more thing they can put on their list of benefits. For employees, it’s something that they get without paying full freight for. For eye-doctors, it encourages people to go to the eye-doctor. For the insurance companies themselves, well it supplies their jobs.

But it’s a whole lot of money changing hands for little or no ultimate purpose. The vision insurance companies may have deals with the eye-docs for reduced rates and all that, but economically that’s not any more logical than AARP and military discounts and the like. It’s a shoddy reason for an industry to exist. The amount in overhead and billing statements and the like far outstrips the benefit that they provide. Hospitals and health care workers have to lean on insurance companies because often insurance is the only way that they’re going to get paid because a lot of what they do can get really expensive. Patient-paid eye care centers, on the other hand, are often quite profitable.

I personally never get vision insurance even if my employer is picking up part of the cost. Simply put, I don’t want the hassles involves. It seems that every bill I get from any regular health care provider ends up being a ping pong match between the clinics and the insurance companies over who must pay what and it seems rare that I actually end up paying what I was told up-front that I should have to pay. The same is true of my dental insurance. It’s all rather incomprehensible. Why should I invite that complex mess into my life for eyeglasses when I can just go up to Walmart and get a prescription written and filled for a stated price that will not be altered because some conversation between two other agents that I am not privy to did not break in my favor?

Is there something I’m missing here? Some real service or benefit they provide that I’m not seeing here?

There’s an interesting bit over at Medscape: most of the expiration dates on medication are pure horse manure.

As it turns out, medications in the US generally are stamped with a really, really conservative “expiration” date. Some foodstuffs that don’t actually expire have expiration dates stamped on them as well. The legal points for meds are that FDA regulations (which I’m sure the pharma industry didn’t fight too hard against) require the medicine manufacturers to stamp their products with a date to which they “guarantee the full effectiveness” of the medicine. For marketing reasons, they generally stamp them at the 2-3 year mark, not because the medicines lose effectiveness that quickly, but because they sell more meds if people don’t realize the things are good (with proper storage) up to 10 years.

On the one hand, if the manufacturer is required to “warranty” the efficacy of their product, it’s probably best for them to limit their liability by not guaranteeing it for too long. On the other hand, by mislabeling that date as an “expiration” date, they’re tricking unwary consumers. Maybe we need some truth-in-advertising laws to come into play here.

Since this post discusses anatomy and bodily functions that some people are uncomfortable discussing, I’m going to put it below the fold. (more…)

This is a post about a college football coach, but it’s not really a post about college football. Bear with me.

At the beginning of the season, there were three obese coaches in NCAA football. Two of which were fired and one held on to his job by the hair of his double chinny-chin-chin. The most curious case is that of the largest of the three, Mark Mangino. Mangino was fired from the University of Kansas after a 5-7 season that included five wins followed by seven losses. He is the first winning coach at KU since the 1950’s and amazingly had the Jayhawks in national championship contention, taking them to the Orange Bowl just two years ago.

Mangino’s firing was the product of a number of factors. Ordinarily, a 5-5 record (which is what Mangino had when the rumors began) is not going to get you fired from Kansas, a basketball school with a history of marginal performance on the field. There were allegations that he mistreated his players, though those conveniently began to surface after KU’s athletics director was telling people that the program was interested in exploring other options. It’s not uncommon for schools that intend to fire a coach to start leaking damning information in preparation, even in cases where the department knew all along what was going on. He was also known for being a difficult individual to deal with.

Even so, sometimes things that aren’t “the reason” and that aren’t stated as “a reason” can play a factor. Combine his appearance with his disagreeable attitude and he very much embodies the notion that no matter how good you are at your job, who you are and how you present yourself can have a profound impact. I believe that it is unlikely that had Mangino been trimmer and more personable, he would not still be the head football coach at the University of Kansas. Nothing I see in his record, up to and including the seven straight losses at the end of this year, is enough to tell me otherwise. There are a lot of stupid AD’s out there, but I don’t think Kansas is stupid enough to believe that they’re going to get coaches that go 12-1 without 5-7 years.

Working in IT, I’ve gotten to know a number of competent, anti-social individuals. What I’ve learned is that being competent is enough… for a while… but eventually what others think about you is likely to be your undoing in the end. If people don’t like you, you will eventually provide them an opportunity to discredit you no matter how competent you are. They will be just waiting, waiting, waiting for those five straight losses. Eventually you’ll hit a slump and you’ll be let go.

People are willing to put up with a lot when you’re winning or doing a great job. Texas Tech coach Mike Leach can be a weird Mormon Pepperine Law graduate in a part of the country that doesn’t think a whole lot of Mormons and educated people, but as long as he is winning, nobody will care. That’s not to say that it won’t hurt your career when it comes to advancement (like Mangino, Leach doesn’t get the job offers his records would indicate), but you’re not going to lose your job over it without some other justification.

Unfortunately, this applies not only to people with significant attitude problems, but people that for no fault of their own defy people’s perceptions of what they should be. This is where Mangino’s weight comes in. The guy does not look like a coach. He looks like somebody whose only exposure to sports is getting hot and sweaty when standing up to cheer for a team from a college that he never went to.

Of course, people look at the fact that there are obese coaches and black coaches* and suggest this proves that there is no discrimination going on. And further, if Kansas was willing to hire an obese guy, they’re not going to fire someone for being obese, are they? Most likely not. But that doesn’t mean that he is necessarily going to be given the same opportunity to succeed and the same margin of failure.

It all makes me think of when I was young and when I was told that it didn’t matter what people thought of me as long as I was a good person that worked hard and all that stuff. Now being a good person and working hard have their rewards, but it was incomplete advice. It does matter that people like you and it is important to be well-regarded. Even if you’re the sort of guy that doesn’t need or want much in the way of friends, social skills and a presentable appearance will make a material difference in your quality of life.

I am fortunate in that people that get to know me generally like me. I am unfortunate in that people do not warm up to me particularly quickly.

I have all the faith in the world that any biological children Clancy and I have together will be some degree of smart. They will also be raised to work hard and all of that. The main area of concern is how well-adjusted they will be socially and that’s something I’m going to have to try to work at. They’ll be at a competitive disadvantage.

Jason Whitlock believes that Mangino’s team was “engulfed by his negative energy, a dark spirit driven by his excess weight. ” Also, perhaps, driven by the way that his weight caused people to look at him. My kids will be smart and they will be capable. God, I hope they’re liked.

* - Interestingly, Turner Gill, who is partially the subject of that article, is slated to be Mangino’s replacement at Kansas.

A couple weeks ago I discussed the gray area involving pre-existing conditions (PEC) and health insurance companies. In the comments, I made an allusion to a health care company that I signed up for that sheds some light on the issue.

Assurant Health specializes in offering short-term health insurance options to people that want individual or family policies apart from employer-financed health care. The terms they attach to their policies actually put their coverage between “insufficient” and “utterly useless.”

Assurant specializes in offering “insurance” on the cheap. Their plans are generally high-deductible and even after you meet your deductible you’re still on the hook for 20%. They may offer a permanent plan, but the policies I’m looking at are their “short-term” policies. Those are the policies that are half-useless. But they do fill a market void.

The way it works is this: You sign up for a plan and it can last for up to six months. The last time I used them, they cost $75 a month despite my smoking. The deductible was $2500 and, as mentioned, you were still on the hook for 20% once you passed your deductible. I’m not sure how much they charge now, though their web site says plans start at $60.

The catch is, though, is that after six months you cannot renew. You have to apply again. Therefore, any illness you got in the previous six months becomes a PEC. And if in the interim you get cancer, there is a good chance that they will refuse to cover you altogether. Which may be just as well because they won’t cover PECs in the first year** on their permanent plans (which cost twice as much) and you can’t get a policy for more than six months.

So why would anyone sign up for this plan? Well, if you get a sudden-but-temporary illness, they’ve got you covered until the policy expires. If you have an accident, you’re covered there, too.

But the reason that I signed on was solely to avoid the gaps in coverage I talked about in my previous post. In essence, I was paying them just so that I would be able to tell future insurance companies that I was insured. Which is kind of screwy, when you think about it.

I’m honestly a little surprised that the insurance companies let us get away with this. You would think that they’d lobby congress to only certify plans that meet specific criteria to count. It’s very likely that, if there were a PEC requirement, we will start to see more such lobbying. Not all of Assurant’s plans are allowed in all states and Assurant does not serve a handful of states. With the exception of some western states, the states with limited services are Blue States. So I suspect it’s a question of how tightly states are regulated rather than state legislatures being overly deferential to Big Insurance (not that these things are mutually exclusive).

Nonetheless, it’s a handy thing to have around for people that can’t afford better coverage. Clancy and I may have to re-evaluate our insurance options soon (her COBRA plan is wicked-expensive and not reimbursed by ARRA). We’re in a good enough financial position that we don’t have to accept this sort of half-coverage, fortunately.

** - You have to have a gap in coverage for PECs not to be covered under group (ie employer) plans. The same is not true for individual policies.

UPDATE: Problem solved! Phew. We’re waiting in anticipation on a possible job offer from Gemini Falls. I think I’ve been much more stressed out. Everybody wish us luck!

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For those of you that have never had to use COBRA, it’s a pretty good thing. Basically, the government told employers that they cannot tax-deduct health insurance unless they supply a plan that allows 18 months of coverage after a person loses their job (for any reason except malfeasance). So employers in turn lean on insurance companies and insurance companies reluctantly comply.

The problem with this sort of government-enforced transaction is that if a company does not want to do business, they can be pretty resourceful about finding ways not to. They delay sending out the paperwork by a month or more, hoping that you’ll make other arrangements. You get 60 days to sign up and if you miss that deadline then they absolutely, positively will not continue your coverage. All claims until the paperwork goes through are denied and you’ll have to recoup the money later. Then, when everything gets settled, you have 30 days to back pay everything you owe, so you have to have three months’ worth of premiums on hand. If you weren’t saving for that like you should have been, tough luck.

I knew all this when I signed up for COBRA, so I expedited things by signing up on their website. I didn’t want there to be any chance of my check “getting lost in the mail”. I also made darn sure that I paid all of my premiums over a month in advance so that they couldn’t make any claims about when the check did or did not arrive. But apparently, even doing everything right is not necessarily enough.

We’ve been simultaneously lucky and unlucky here in the Truman household. Rather, our luck has managed to mitigate the damage of our extraordinary unluck. Although I don’t know if you can call it unluck if it’s dependent on the bad-faith actions of others. In this case, the culprits are former employers and insurance companies.

We came back home from our Great North by Northwest Jobs tour a little bit earlier than expected. It actually wasn’t a welcome development because we were hoping to swing back by Gemini Falls and sign some papers. But home we came and it was a darn good thing we did. In the main was a letter from the health insurance administrator informing her that her COBRA enrollment period had lapsed and she is not only uninsured, but has been uninsured for the all-important 60+ days.

This was crazy because we knew for a fact that she sent in the money. We also know that the mail was taken that day because another letter sent that day was received a couple weeks prior. So she called her health insurance administrator* (HHIA) and they said that they had in fact received the check but that ARRA** had been denied so they sent it back with a letter explaining that she needed to write another check (for more money).

So suddenly her insurance went up from $200 a month to $600 a month because the federal government wasn’t going to kick in. Why wasn’t the federal government going to kick in? Because her former employer declared her termination “voluntary”. Given that she was on a one-year contract just like I was and that (immediate) renewal of said contract was not an option, that just didn’t seem right to us. Either her employers were being jackholes or my employers were being unexpectedly generous. I’m disinclined to believe the latter. But whatever.

We had 14 days from the date of the letter to get them the contract and full amount of the policy back to them. This was on a Friday. Day 14 was Monday. We could fax them the signed contract, but not the money. Further, that Monday we were going to be driving back to Gemini Falls for a second interview. Long story short, their corporate headquarters was in Zaulem and I woke up at an ungawdly hour of the morning to go out there and hand-deliver the check. It turned out that the 14 days was 14 days inclusive and ran out on that Sunday. Fortunately, they’d put a flag on the account and so they were going to give us an extra couple of days. That was the only good turn we got from just about everyone we’ve dealt with.

About the same time that we got the letter from HHIA, I got a letter from my New Health Insurance Administrator (NewHIA) saying that FIREA, my former employer, had signed a contract with them and that they would be taking over starting on 12/1. They also sent me an Open Enrollment letter to. Notably, it would be cheaper for her on my insurance than it was on hers***.

It was cheaper with or without ARRA assistance and the wording was vague as to whether or not I could get ARRA assistance even though it had been denied for her. My guess is that we cannot. But even then it’s cheaper and I feel better paying one health insurance administrator rather than two. But I thought I would call NewHIA and see if ARRA might be covered and what the bill would be.

That was when the anvil fell. NewHIA informed me that my policy had been canceled. I had to sign up within 60 days of eligibility and I became eligible at the beginning of August. I should have received a letter. But the only two letters I had from NewHIA were the one informing me that they were taking over (and that I had a bill to pay before 12/1) and another about Open Enrollment. Long story short, as far as they knew, I’d never signed up with OldHIA. Except that I had and I was actually a month ahead on my dues because I paid a couple months ahead. A whole lot of good that did me.

NewHIA told me to contact OldHIA and have them forward my information. OldHIA said that they really couldn’t do that, but at the end of my policy they could send proof that I had been insured. That was not acceptable because that would create a gawdforsaken gap that could give NewHIA cover to cut my COBRA coverage completely (again). I asked them if they could send me a copy of the document. She put me on hold, came back, and said she could. But it would take two weeks. In two weeks, my coverage lapses.

I called NewHIA again and got a very unhelpful woman who said that there was nothing she could do without something from OldHIA proving that I had been insured. She suggested I call FIREA. So I called FIREA and they said that they would look into it. Perhaps she was just a good actress, but I got the feeling from her that she actually will.

So that’s where things stand right now. I actually run a not-insignificant risk of having my insurance cut off due to no fault of my own. I signed up within 14 of the 60 days alotted to me to sign up for COBRA. I have not only paid every bill on time but I am actually a month ahead. But none of that matters because NewHIA and OldHIA can’t talk to one another and I’m relying on FIREA, a company that has not been a friend to me and that could care less if my insurance is cut off. NewHIA will not accept an enrollment form or a check as long as my account is listed as “canceled”. Further, I’m going to be out of town for the remainder of the month starting on Friday and I won’t be back until after the lapse date, so I can’t have anything mailed to me. I’m not sure that matter because everything seems to take 5-10 business days to get mailed anyway.

And even if this does straighten out, there is virtually no way that I can get Clancy on my plan. That’s due on Friday and they’ve made it clear that there are absolutely no exceptions. The likelihood that this will all be straightened out Friday is pretty small. If ARRA doesn’t cover it, and I don’t believe it does, it may not be worth the effort anyway.

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* - Health insurance administrators appear to be all the rage. Basically, instead of dealing with your employer or the insurance company for your health insurance, you deal through a third party that coordinates it all. Somehow, this adding of another layer of organization is supposed to save people money. Maybe by creating miscommunications like this.

** - ARRA is the part of Obama’s stimulus wherein the government helps unemployed people by paying 65% of their insurance cost.

*** - This is sort of topical. Republicans are trying to allow for insurance companies to “shop across state lines”. As it happens, I am insured by Blue Talon of Estacado, the same insurance company that I had when I was in Estacado. Since my employer is based out of Estacado, they can get away with that I guess. I doubt it’s a coincidence that insurance in less-regulated Estacado is cheaper than insurance in more-regulated Cascadia. I’m probably not as protected, though.

One of the ongoing factors in the Health Care battle in congress is the issue of pre-existing conditions (PECs). It’s one of those issues where it is hard to strike a compromise that is fair to both consumers that have PECs and the insurance companies (and, by extension, their customers).

On the other hand, if all pre-existing conditions are covered no matter what, there is little incentive to get health insurance until you need it and an incentive to get something high-deductable until you need an insurer that’s going to cover whatever it is that ails you. Some, such as Megan McArdle, argue that this is not really such an issue, but I would expect it to become a much larger one as people get accustomed to the idea that they cannot be denied insurance due to a PEC. As it stands, I know someone that was uninsured, needed surgery, and cheated a single-issue insurance company by not disclosing it.

On the one hand, if PECs are never covered, people who happen to get sick while ininsured are forever locked out of the system even if they’re uninsured for brief periods of time. Or even if you were insured at the time, but for one reason or another have to switch insurance carriers. Further, PECs are frequently used by insurance companies for the sake of rescission.

Rescission, for those of you that don’t know, is when a policy is retroactive vacated. Insurance companies claim to do this when a customer was not up-front about a PEC. The problem is that some of the PECs used to vacate policies are things that a customer doesn’t even know about or that does not strike someone as significant (particularly if it’s something that hasn’t come around in a while). For instance, someone with a family history of heart illness or that had an irregular heartbeat in 2003 could find his policy vacated in 2009 when the insurance company finds out and argues that it needed to be informed.

The current balance that has been struck is that as long as one has maintained consistent coverage without a lapse over 30/60/90 days, they cannot be denied coverage on the basis of a PEC. State laws vary as to what length of lapse is acceptable and how long PEC coverage can be denied. In Cascadia, you have to have a lapse for greater than 60 days or so and if you have one they can deny you for up to 12-18 months. Further, rescission is generally only available to single-issue policy holders. In other words, you generally are not cut lose when covered through your employer.

This strikes me as a not-unreasonable balance, though I’m not sure it’s sufficient or proportional.

To take an example from the Truman-Himmelreich household, there was a snafu in the paper work for Clancy’s COBRA coverage* that lead us to find out, more than 60 days after coverage lapsed, that she had not been covered. So by default, we’ve already got a lapse that prevents anything pre-existing from being covered for a year. And I believe Cascadia is the most generous state I’ve lived in as far as this goes. I don’t believe Delosians are similarly protected, though I could be wrong about that.

As mentioned above, you generally have to have some sort of penalty for people that let coverage lapse during health, but the difference between enrolling in 70 days and enrolling in 59 days should not be that dire. A more fair approach would be to say something like “PEC do not have to be covered for whatever time period one was uninsured.” So we would not have any PEC coverage for 70 days. That seems fair to me. We would not have an incentive to wait as long as we wanted until we needed it since the longer we waited the longer it would be before we were completely covered. As it stands, we would have to wait nearly as long (within six months, anyway) as someone that went five years without coverage.

Rescission is a tricker issue. On one hand, insurance companies ought to be able to deny people that cheat the system. People should not be able to do what my friend did. The law didn’t stop him, but that’s only because the insurance company did not know. Meanwhile, however, insurance companies have picked up the practice of taking someone’s money until they suddenly have need of the services offered and only after that investigating someone’s application form and finding some (alleged) discrepency.

If an insurance company is collecting someone’s money, they ought to be relatively assured that they have coverage. Only those cases where insurance companies have reason to believe that fraud is involved should they be able to rescind. Insurance companies say that’s what they’re doing now, but frankly I do not believe them. They have too much financial incentive to do otherwise.

My proposed solution to that would be similar to the previous. Once an insurance company has been collecting premiums for a specified period of time (I’m inclined to say six month or a year), they should not be able to rescind a policy. Someone that hasn’t made any substantial claims in a year but continues to pay their premiums has demonstrated a degree of good faith. Someone that needs knee surgery is not going to pay $300-800 a month for a year just to collect benefits. Someone that is at risk of a heart condition didn’t start buying insurance with the plan of having a heart attack in a year’s time.

Now, both of these cases would have an exclusion for outright fraud. The difference between that and now is that the insurance company would have to prove that any reasonable person would know that a PEC was relevant. In other words, a heart attack a year before the policy could be considered fraud, but a heart murmur four years prior would not. A pack-a-day smoker that does not disclose his habit would be game, but family history that may have escaped their mind would not. Beyond that, the insurance company has the option of paying for (or splitting the cost of) a complete physical rather than not worried about it until it suddenly becomes very convenient to do so.

The other issue at play is that as medical records become more electronic, it’ll become harder and harder for people to knowingly (or unknowingly) hide PECs. There are questions as to what the insurance companies should and should not have access to versus the right of doctor-patient privilege, though it could well be that a compromise could become that if a person submits all of their medical records that there can be absolutely no rescission. Right now it’s not easy to collect that information, but it’s one of those things that (for better or worse) is going to become a lot easier in the coming decades.

* - For those of you that don’t know about COBRA, it’s a pseudo-mandate by the government that requires insurance companies not to drop coverage if you lose your job. What happens is that you get COBRA paperwork after you lose your job (for any reason excluding malfeasance) and if you respond within 60 days and pay the bill, you’re retroactively covered.

The downside is that you have to foot the bill that your employer previously footed. In a case like mine, that’s diddly. But when employers are actually generous with their benefits, you can see your premiums jump three-fold or more, as was the case with Clancy. The other downside is that since COBRA was something that was thrust upon them by the government and the policy-holder’s employer, it’s not something that they’re excited about and it’s frequently the case that they don’t want your business.

On the other hand, President Obama’s stimulus package included a provision wherein the government will pick up 65% of the tab. For people like me, that means that COBRA is cheaper than penny-pinching employer-provided health care. For people that have more generous benefits like Clancy, though, it’s still going to cost more.

I happened to catch this story on the Today Show this morning:

Lauren Johnson is a typical 12-year-old girl - except that she can’t stop sneezing.

It is so bad that she sneezes up to 20 times a minute, or 12,000 times a day.

The non-stop sneezing began two weeks ago when Lauren from Virginia in the U.S. caught a cold.

Lauren can’t go to school and is even struggling to eat.

The only relief she gets is when she falls asleep each night. Her condition has left doctors baffled.

Cynically, my first thought was that she simply figured out how to sneeze on cue and is faking it (particularly since it doesn’t happen in her sleep), but she sold me during the interview. Not only does she look miserable, but she looks a particularly disconcerted sort of miserable that I don’t know a twelve year old would think to use.

What really stuck out in the story was all of the tasteless puns TTS was throwing out there. Pretty tacky.

Sometimes we want things from society and the law that we cannot get. For instance, you may believe that abortion is murder or that the death penalty is wrong. However, in most places (well, all places in the former and most places in the latter), you are unable to actually do anything about it. It’s a frustrating situation to be in. Most of the time when this happens, though, we view some wrongs as being more wrong than others. I’m opposed to the death penalty, for instance, but if we’re going to have a death penalty then we ought to try to make sure that (for instance) those that are executed are not tortured in the process and that innocent people are not executed.

Despite my fundamental opposition to the death penalty, I tend to get annoyed with death penalty opponents who play a sort of cat-and-mouse with partial measures. It’s one thing not to want someone to be executed in a way that is tantamount to torture. It’s another to say that method-X is torture. But to suggest that method-X is torture is primarily to suggest, in the short term, that some non-tortuous method is used. The trouble is that when you turn around and suggest that any alternative is still killing people, you’ve undermined your case against method-X. You have revealed that your opposition was to the act and not the method involved. You’ve alienated anybody who generally supports the death penalty but was concerned about method-X. If method-X is genuinely torture, you’ve possibly consigned people to death row to a more tortuous death than would otherwise possible. If method-X is not really torture, you’ve been remarkably dishonest and people (who already disagree with you in bulk) are not unlikely to notice. On the other hand, if and when method-X is replaced by method-Y, you’ve lost a good portion of your argument if your argument was never really against method-X to begin with.

This is why the whole argument about the lethal injection formula at work in our death chambers left me somewhat cold. The fact that the point was never to switch to a more humane method left me skeptical that the fomula (method-X) was really as bad as they were saying. Supporters of the death penalty didn’t even have to say a word. I could be right about that or I could be wrong about that, but that was the impression that I got.

This sort of frustration is how I always feel about nutrition-boosters. I can’t tell you how many discussions I’ve gotten into where I’ve been tut-tutted for liking some food, been told how awful it is for me in terms of fat and lack of nutrients, then listed the nutritional information off the top of my head. Yes, for foods I eat frequently, I remember these things. Turkey pepperoni, for instance, is not appreciably worse for me fat-wise or calorie-wise than sliced turkey on a sandwich. No, it’s not completely stripped of its protein (any more than a turkey sandwich). Yes, a salad would be healthier, but the most likely alternative to a turkey pepperoni snack is not a salad but is cheese. Yes, the cheese has more calcium, but it also has a lot more fat… and wasn’t that your original complaint about the turkey pepperoni?

The real problem, I have come to determine, is not so much that I am eating turkey pepperoni or inulin. It’s that I’m not eating what they eat. Now, if I’m asking for advice on how to lose weight, suggesting replacing turkey pepperoni with celery is some darn good advice. And maybe the turkey pepperoni really is bad for me in some way that I can’t measure. But it becomes rather obvious to me that they really don’t care if it is or not. It’s consumer food. Consumer food is evil.

That’s how I feel about a lot of the complaints about unhealthy beef. It’s not that I don’t think that there’s a problem with tainted beef. There is! I want it fixed! In fact, I think that I want it fixed a lot more than the people screaming most loudly about it. For them, it’s like method-X insofar as it is a tool to their ultimate goal of getting me to stop eating beef. As a beef eater, though, I have more of a stake in how healthy or unhealthy the beef I eat is.

I am reminded of this by a post by Marion Nestle, last seen accusing a 20oz Coca-cola drink of having 800 calories, who argues that irradiation isn’t a particularly good idea. Why is it not a good idea? Because killing bacteria lets the industry get away with producing beef with bacteria in it {cue nefarious music}. So she has now demonstrated that E. Coli is really secondary to the evilness of meat producers.

I’m not arguing that meat producers are benevolent entities nor am I denying that they are guilty of all manner of things including gross mistreatment of cattle. Maybe a law should be passed about that. But every other recommendation (mostly involving testing and handling of meat) I’ve read has come across as far less likely to actually reduce bacteria and more likely to make meat more expensive and the industry less profitable. And it becomes ever more apparent to me that the issue has little to do with bacteria at all and more to do with punishing thy enemy and forcing people to eat less beef.

On a relatively unrelated note, I find it fascinating how bacon became at some point the classy, hip meat. Would the above article have been written if the E. Coli had instead been found in bacon? Oh, probably. But there’d probably be fewer people solemnly nodding their head at the notion that Middle Class America Knows Not What It Consumes.

Over at “The Frisky”, the question is posed: does the “fat acceptance movement” glamorize unhealthy living?

America’s in a weird situation. On the one hand, we overly glamorize people who are WAY too thin to be healthy. On the other hand, the “average American” is definitely heavier than they should be and the trend’s been going upwards.

As far as my weight goes, I’m not dissatisfied. The woman I have been dating recently finds me attractive. I find her attractive (she’s not stick-thin, which I would hate, but definitely does not resemble Mr. Stay-Puft either). I could do to lose ~15-20 pounds, but the methodology by which I would do so is partially related to necessary changes to my lifestyle (a shorter commute, adjustment to my work environment to allow more standing and moving around) that are currently “in process.”

In the Colosse area, we have quite a few (mostly Latino/Black, indicating perhaps a cultural thing) women who walk around in spandex or revealing dresses while retaining body shapes more suited for the aforementioned Marshmallow Person. A fair number of them seem to believe that they are (despite a physical shape indicating extreme unhealth) the epitome of attractiveness.

As one commenter points out, a normal person doesn’t get to 300 pounds on a single bowl of cereal and a sub sandwich each day, unless the “bowl” is a punch bowl and the “sandwich” is one of those party-size setups. If you somehow do manage to get to that size without such, you have a serious medical condition - such as insulin resistance, or PCOS, or some other major hormonal/metabolic/digestive imbalance - that you should be seeing a doctor about quite regularly. And I can’t quite condone the idea that people should simply “accept” these medical problems, and leave them untreated, either - there are simply too many related risks down the road.

I also suspect that much of the supposed self-confidence of the “fat acceptance movement”, much like the (slightly more underground or at least less vocal, though I have seen it through the lens of an anorexic friend who thankfully got help) pro-anorexia movement, is more bravado to hide deep-seated mental issues than anything else. Anorexics don’t try to tell people “I don’t eat”, they try to avoid those social situations or try to appear to have eaten. Bulemics eat, and then try to reverse the process in secret. Likewise, the “fat acceptance” types are probably engaging in a number of lies or even self-hurting tactics (eating in secret, or redefining mentally what a “portion” means, which is an ongoing problem in a culture where “fast food” comes in ever-larger burgers and 42-oz helpings of HFCS that won’t set off the body’s chemical saitety triggers).

The military is looking at banning smoking in the military. I didn’t really have an opinion until I read the explanation:

Jack Smith, head of the Pentagon’s office of clinical and program policy, says he will recommend that Gates adopt proposals by a federal study that cites rising tobacco use and higher costs for the Pentagon and Department of Veterans Affairs as reasons for the ban.

Now smoking is bad for you for all sorts of reasons. And there are reasons I could see it being particularly bad for soldiers. It cuts into stamina, disrupts sleeping patterns, and so on. And the military is a place where the “freedom to be” does not really exist. So there are a number of reasons as to why I could support (or at least decline to oppose) a ban.

Health care costs, however, are not among them. Soldiers are not like senior citizens on Medicare or less fortunate citizens on Medicaid. They don’t get health care out of the goodness of the hearts of the federal government and its taxpaying benefactors. They get it because they served our country. Just as the GI Bill is not a gift, neither is the VA. If we’re going to put them in harms way and in stressful situations and if they need to smoke to cope with that and we’re not worried about the effect it would have on their job performance, then paying for some emphaczema tanks and lung cancer treatments is really not something that we should get huffy about.

#1 - Everything you have heard about hospital food is true. It is bland. It is mushy. It is as unseasoned as can be. In any other possible situation, I would be doing everything in my power to lend it even the tiniest bit of gastronomical excitement.

But if you’re in a hospital, it is exactly what your body needs to be fed.

#2 - They will not let you sleep.

I take that back. They’ll let you “sleep”, as in take naps. They’ll just be by every 3-4 hours to check your vitals, and wake you up in the process.

#3 - Having an IV line in, no matter what the reason, sucks. It makes it pretty much impossible to move one arm. If you want to get up and move the 10-15 feet it takes to reach the toilet, you have to get up and wheel the IV cart along with you. If you do fall asleep and move the arm, or accidentally make some other motion (say in the process of lifting up the hospital gown to set your posterior on the toilet) and temporarily block up the IV line, the IV cart will set off an alarm.

That last part is probably actually for the best.

#4 - Hospital gowns are the weirdest item of clothing ever imagined. They grant you the illusion of being covered, while covering virtually nothing. They grant almost no protection against the elements. You might as well be wearing just your underwear.

Yet here I sit, in my underwear and a hospital gown, and grateful to be wearing both.

#5 - Hospitals are COLD. Especially at nighttime, they are exceptionally cold. I’m guessing it has something to do with maintaining a sterile environment and keeping certain bacteria/fungi from growing.

I am very grateful to have three blankets over me tonight.

#6 - Thankfully, the idea of cell phones/laptops/etc being banned from hospitals appears to be pure bunk.

Now to try to get another catnap.

When it comes to most things that are toxic or otherwise unhealthy in anything but small quantities, people build up a tolerance. You drink caffeine and you start needing more and more of it to achieve the same effects. Of course, tolerance for drugs is an extremely big deal as junkies consume more and more to try to get that same high. Generally speaking, people with a vice try to acquire stronger and stronger variations of that vice to keep going.

Two exceptions that I’ve noticed, though. In my experience, it seems like the more regular a drinker and the more regular a smoker is, the more likely it is that they consume notably inferior product. Instead of building up a tolerance, there is a sort of reverse tolerance where it the quality matters less and less so long as you’re going through the motions.

Very, very few veteran smokers I know still smoke brand name cigarettes. Obviously, if you’re a full-time smoker, cost becomes more of an issue so you don’t want to waste your money on a premium brand if you can get something cheaper that’s almost as good. That’s just common sense.

It goes beyond that, though. First, even those that do smoke brand names seem to smoke lights instead of regulars. And those that go off-brand typically do not gravitate towards brands that produce a similar taste. They instead move towards blandness. Sometimes even light variations where the flagship product is relatively tasteless.

I’m not sure why it’s different for cigarettes and alcohol (where the people I know that drink the most beer frequently drink light beer). Maybe because these products are relatively cheap and accessible compared to drugs. You never have to worry about where you’re going to get your next one from.

A bigger issue, though, I would be that both cigarettes and alcohol serve a cause beyond the infiltration of chemicals into the system. Despite the hit that it’s taken in recent years, smoking remains something of a social activity (outside Deseret, anyway). Drinking, of course, is social as well. They’re also both things that you do while doing something else. I honestly don’t care for the taste of beer, but I enjoy beer as part of a beer-and-football or beer-and-music-show combo.

Because of this, if you partake in the heavier stuff, you can’t do as much of it. One of my favored brands of cigarettes, Maverick, simply can’t be taken in large quantities. It’ll make you sick. Meanwhile I could smoke Cheapo Lights all day (though really, that crosses a threshold of pointlessness for me).

On the whole, I really haven’t fallen prey to the reverse tolerance. In fact, I wonder if I’ve built up real tolerance.

When I started smoking, I started with Marlboros. It’s pretty much the default brand. When I became cost-conscious, like many smokers I started going for discount brands. I settled on Doral at first, though made the shift to Pall Mall. Doral was always pretty inexpensive and the difference in taste was mild enough that it was worth it. Pall Malls had the advantage of often being quite cheap and tasting similar to Doral but with much slower burn times, allowing a smoke to take closer to 10 minutes than 5. I would also smoke Mavericks, though as I mention earlier they act as their own deterrent sometimes.

At some point, though, Pall Malls changed or my taste buds have. My former brand-of-choice may have changed their formulas. They taste like Light cigarettes now and so the main point of buying them anymore is that I enjoy them less and will smoke less. Mostly, though, they taste like the ultra-cheap cigarettes that I could never really get in to. I find that I mildly prefer to get Maverick cigarettes now. Mavericks have a similar benefit in that you can’t smoke too many of them without getting sick and that acts as its own deterrent. When I’m not in the mood to make myself ill, I get USA Gold, which is a sweet spot in between the two.

Odd factoid:

In 1951, the US government officially retired “old age” as a possible cause-of-death to be listed on a death certificate.

Today, we point to all sorts of causes, and the form requires at least one “primary cause”, plus as many secondaries as can be mentioned.

The form also says: “Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about conducting an investigation or providing assistance in completing the cause of death.” While this may have a certain truth (medical research asking, for instance, “are more old people dying of brain or heart failure” having some value), I have to wonder, can we not just admit at some point that yes, certain people just reach a point where their body gives out?

I can say this much - I’d rather be told that a 90-95 year old grandparent died simply because “it was their time”, than to have to listen to a doctor bluster on about the myriad number of causes and case history that was going on the death certificate, and I’d probably feel better knowing that the first thing on the certificate itself was an acknowledgement of simple mortality. Sure, put all the “extra causes” you want after that if it helps aggregate statistics for medical research, but just admit that we don’t live forever.

Every Friday morning the office buys us donuts. I appreciate the regularity of it. At Monmark-Soyokaze, they would surprise us with them. That was nice, except that it invariably happened on mornings that I already ate breakfast before coming in. This way, I can plan around it.

These days, though, it’s a moot point because they’re in at 9 and gone by 9:30 and I don’t get into the office and settled in until 10:00 usually.

I took yesterday off because I had an eye appointment, so I have some time to make up. So I came in at 7am. I’m not sure why, but for some reason I started getting really hungry. So hungry that I was considering having more cereal. Then lo and behold, what do I get? An email informing us that the donuts have arrived.

I’m never this lucky.

Then again, given the health content of the donuts I eat, maybe this isn’t really luck.

They’re here by 9 and gone by 10. Since I typically don’t get in and settled in until 10 or so, I almost never get any. Even so, I appreciate the

Last weight post. I promise! For a little while, anyway. This post is going to cover some ground covered in my previous post about Inulin. This one was written first and Inulin became a hot news topic before this went up.

I wrote twice before about how people that have never really, truly struggled with their weight (losing 10 pounds to look good for your high school reunion doesn’t count) don’t understand how complex the process of losing weight is. At least from a psychological perspective. Another factor is that people lose weight in different ways. What works for one person does not mean that it will work for another. For instance, if you have one guy that loves cheese and pork and doesn’t have any real use for bread and crackers and put him on the Adkins diet, he’s much more likely to succeed than a bread-lover with a fondness for pastries. Even though they may have will-power, self-control, and discipline in equal measure, the results won’t be equal.

I have personally found that a couple of minor tweaks made all of the difference. What matters most for me is simplicity. Anything that requires me spending a whole lot of time counting points is likely to lose me. I’ll lose track of how many points I have for the day, get frustrated, and put the diet off for another day. Likewise, anything that requires of me to not eat cheese isn’t going to happen. Or a diet that says that if I drink a coke, I’m screwed for the day. I need room for a little bit of sin, lest I end up settling for a lot of sin.

I decided after moving up here to make one and only one major, written in stone change: I will eat my daily allotment of fiber at least five days a week. My initial thought was that I would try to do this, see if it did any good, and then if not I would find some other simple rule. I figured that by then I would have the habit of eating fiber and therefore taking the next step (whatever it might be) might be easier. Turned out that the fiber created a cascading effect of virtue.

Partially, I think, because of how I chose to get those calories: High-fiber cereal. Really high fiber serial. I eat 80-90% (or more) of my daily allotment for breakfast. That has the benefit of getting breakfast into my system at the beginning of the day. As everyone knows, it’s better to eat more meals of smaller quantity than fewer meals of greater quantity. I always knew that, but could never manage to do it. But breakfast set the stage for that. And it prevented me from going out and getting breakfast of a much worse sort. I did have to strike out a compromise and created a compromise: I get to eat breakfast at McDonald’s on Wednesdays. I gave in on this so that I would always have McDonald’s to look forward to without eating it on too regular a basis. To say that I’m never going to eat there is to set myself up for failure. Knowing which day I will be eating there helps solidify the thing to look forward to.

In addition to preventing greater dietary sin, the cereal keeps me full until lunch. For lunch I really lucked out. Another example of how an external circumstance can make all of the difference in the world. Mindstorm, my employer, has a great employee cafeteria. A wide selection of food at reasonable prices. But the biggest thing is that it’s a very short walk away. That’s how I learned something about myself: One of the problems in the past is that I have a psychological fixation on the notion that if I invest time and energy to go some place for lunch, I am going to do some serious eating while I am there. Since going across the street to the cafeteria is no great inconvenience, it’s incredibly easy to just get a quick, relatively small thing.

Sometimes I do get hungry later in the day, so I try to keep a box of cereal at work that I use for snack food. I did this after I realized that I was starting to go to the vending machine to satiate that end-of-day hunger. Plus, Mindstorm has free milk. So that works out. But the important part of this is not what I eat, it’s that by having fewer dietary problems (now I’m eating a good breakfast, eating a smaller lunch) I am better able to identify what the problems are and come up with solutions. It’s not so overwhelming anymore. The more changes you have to make and urges you have to fight off at once, the exponentially harder it gets to make them. I know someone that quit smoking this way, by-the-by. He just got rid of one cig a day per week (the third after lunch, the second in the morning, etc) until it wasn’t worth bothering anymore.

Dinner varies pretty wildly. When Clancy’s not on a horrendous rotation, she cooks and she makes enough for two. Otherwise I usually open something canned or in some cases just have a snack at night. The canned foods are generally not very healthy. But they’re not ridiculously unhealthy either, unless you count sodium. If I’m really hungry it’ll be some sort of pasta like Beefaroni or maybe spaghetti. Chili and/or a burrito is also an option. If I’m less hungry, I’m more likely to eat soup or just get a snack. The snacks are usually not of the healthy sort. They often include Spam.

I’ve recently expanded my attempt to include a morning workout. The workout is actually not entirely for weight. It’s partially an issue of general health and partially in anticipation for my next chore. One thing I don’t mention above is that I still drink three cokes a day and that’s not good. So I’m going to try to make a change there, too. But I know that I have to actually be ready for it in more ways than I currently am.

So for all of you I don’t know how many of these tricks might work for you. I think that it is really important to recognize that overweight people generally have bad habits in different ways. I really don’t think that there is any diet out there that is right for anyone. I think that boosters of one diet over the other (say low carb vs low fat) often mistakenly give people the impression that the way that they lose weight is the only way to do so. According to low carb people, I should be ballooning up about now when in fact it’s my low-fat diets that have historically proven to be more successful. When my wife diets, she has to go all-in. Whenever I go all-in, I burn out and fail.

Of course, what works for me may not work for anyone else. Indeed, what worked for me in the past stopped working five years ago. It used to be that I lost weight by going all-in, spending a couple days eating scratch and then slowly working my way from there. When I lost 70 pounds at the end of high school, that was how I did it (albeit not completely with intent).

Last week I ran across an MSN list about weight loss with a mathematical oddity. In the process of trying to track it down, I read just about every diet-related thing that they have. What struck me as I was reading was how many of their “tips” just didn’t apply to me. It warned against monotony, for instance, but for me monotony is a powerful thing. Creating “defaults” so that if I’m not in a particular mood for something else, I’ll eat the same thing every day. For the author of the article, though, it was a recipe for failure.

Ten years ago little changes were hard for me. Now they’re the only way that I can make changes. Ten years ago eating a little bit of cheese meant that I would go hog-wild. That’s not the case anymore. Ten years ago I could completely steer clear of cheese and sweets. I can’t anymore. Some people need carbs and others need fats and asking them to go without is completely counterproductive.

It seems to me that the best way to go is with an eye towards knowing what your limitations are and what your strengths are. My strength (and weakness) is that I am a creature of habit. I don’t get tired of foods. There are also some ubiquitous foods that I can almost completely eliminate from my diet such as french fries. There are others that I can’t. My wife’s diet includes sacrifices I could never make. Sacrifices I’ve made without little effort are things that would require the world of her.

For me, right now, the path to success is replacing one bad habit at a time.

One danger of forward-dating posts is that between the point when you write it and when you post it, something hits the news that changes the reader’s perception of everything. Seriously, what are the odds that in the week in between my writing of a post involving fiber and it’s scheduled posting, that fiber would be in the news? Particularly the exact kind of fiber involved in the post?

Slate has an buyer-beware article on faux-fibers such as polydextrose and inulin. These don’t constitute real fiber, Jacob Gershman says, and Megan McArdle agrees. The implication, of course, is that people reading this need to go eat raw roots, nuts, and berries if they want to be healthy.

Unfortunately, I think this attitude has precisely the opposite effect. Instead of telling people what the true and good things to eat are, they sort of lead us to throw our hands in the air and say “What’s the point?” It’s sort of like that guy that, whenever you say so-and-so is bad, points to the alternative and says “that’s bad, too!” And we sort of end in this no-man’s land of nutritional post-modernism wherein whatever you’re doing, you’re doing it wrong.

Okay, that’s an exaggeration. Boiled roots and steamed beans are good for you. No one really contests that. And I get it. I get the notion that as long as I’m not eating things that I have no use for, I am a dietary sinner. I might as well be eating pig lard covered in triple-refined sugar.

One of the problems I have with the medical establishment in general is that they often have the perfect tendency to make the perfect the enemy of the good. I tell my phys ed coach that I’m drinking orange juice, and I’m warned about the sugar. People get excited by new games and game systems like DDR and the Wii that encourage exercise and they go out of their way to say that the exercise isn’t as good as the exercise you might get on the treadmill. I half-expect them to complain that the treadmill isn’t as good as jogging, which isn’t as good as carrying logs, which isn’t as good as pushing boulders in persuit of building a cave.

The problem I have with this is that for most people, the alternative to natural orange juice is not prune juice, it’s Sunny Delight or Mountain Dew Livewire. The alternative to the Wii is the XBox. The alternative fake fiber is not a breakfast of… I actually don’t know of any breakfast that they haven’t told us is killing us at some point in the last ten years. Eggs, bacon, oats, orange juice. Maybe a pear and a grass salad is okay. Or eggs, if you strip it of the part that tastes good and don’t add anything to add taste (cause it probably contains sodium, which as well all know will kill you).

The more personal problem I have with it is that more than any other product I can think of, the one thing that has helped my life more than any other is the fake fiber discussed in this article.

When I moved to Cascadia, I made only one conscious dietary decision: to eat more fiber. I decided to do this with fiber-enriched FiberONE cereal. FiberONE contains inulin, which is discussed in the Slate article. Since making that decision, I have lost 35 pounds.

I drink three or four cokes a day. I eat McDonald’s for breakfast once a week. Donuts once a week. If I really want a burger or a couple pieces of pizza, I eat it. I put cheese in the canned pasta I not-infrequently have for dinner. I have not once said “That’s unhealthy. I shouldn’t eat that.” But the weight nonetheless came off.

It would be silly to attribute it all to the cereal. But what happened was the cereal replaced the far, far less healthy breakfasts that I had been eating. It got me to stop skipping The Most Important Meal of the Day. It kept my bowels regular. It suppressed my appetite. It got me started on the right foot. So when it came to lunch, unless I actively wanted something unhealthy, I would continue the trend that I set myself in the morning and get a boca burger. Since I’m less hungry (or have been hungry for less time), I’ll eat less.

If I had read this article before I’d made that decision, I never would have started eating the cereal. I mean, what’s the point? It’s not real fiber. You might get the impression reading the article that there was nothing worthwhile in the product at all. A waste of time. I might as well be eating at McDonald’s.

McArdle makes the comment that the FDA should release a statement saying “If it tastes that good, it isn’t good for you.”

In some people’s minds, it’s as though something tasting good is immaterial. Or that, if they really tried, they’d learn to like brussel sprouts. Maybe, if raised on it, they would.

But things like taste and convenience matter. They matter a great deal. Because without it, people will not continue to eat it. They will likely default to something far, far less healthy. If putting a cheese on a veggie burger makes me like it, it’s worth the added fat because it means that I will have liked my veggie burger and will eat it again. Struggling with no cheese or soy cheese may be acceptable, but it won’t have me coming back for more. That double cheese-burger, which I know will satisfy me, will call to me evermore loudly.

Granted, I am fortunate in that if I do the right things (and even some of the wrong ones), I will lose weight. I recognize that others don’t have it so easy. For whatever reason, they have to sacrifice a lot more to get a lot less loss in return. So for them, maybe these articles are worthwhile if they wonder why their high-”fiber” breakfast isn’t doing the trick.

But I think that a large part of the problem with obesity in this country has less to do with too many people thinking that faux-fiber is actual fiber and a lot more to do with being made to feel guilty any time they eat something that they didn’t pluck from the ground themselves. Diets are notorious for being short-lived and ultimately resulting in weight gain. They tell us that we need to not just go on a diet, but change our lifestyle. But anything convenient or tasty is off-limits.

That’s a recipe for failure.