On Health Care Price Transparency

(from the comments)...

A doctor on billing practices:

Generally such figures do not reside within the physicians’ office. On our side of the table we do some procedure with multiple specifications and generate some CPT code(s) (e.g. a lap cholycystectomy is 47562, add on a common bile duct exploration and it becomes a 47564, and if you just do cholangiography it becomes a 47563). Generally, we couple that with an ICD-10 code that specifies your exact disease (K80 for simple stones, K81 for cholecystitis, etc.). We then dump those codes into a computer.

Can either of those change? Absolutely, we find a bunch of friable neovasculature around the gallbladder, congrats you likely have cancer which means this surgery is now both a different CPT code and a different ICD-10 set. Maybe only one does – we find the gallbladder lacks an obstructing stone, but does have transmural inflammation then you get a new ICD-10 code. If we find that you actually have multiple obstructing stones and we need to go deeper into the biliary tree, then those are different CPTs.

Regardless, we do what is medically indicated, document the codes used.

At this point, unless your physician keeps billing fully in house, those get handled by a processer. Often, bills from multiple providers get handled by one processor who in turn gives insurance companies bills to their specifications. Often this involves a bunch things – where was the surgery done (through very complicated rules, critical access hospitals, for example, can charge more for the same surgery because the government wants to keep them solvent lest a bunch of people lose their local emergency room and OR), who was doing it (e.g. there is a different rate if you have medical trainees involved), and of course stuff about you (e.g. complex patients get reimbursed at higher rates with the expectation that, on average, the higher rates cover higher complication rates and insurance doesn’t incentvize surgeons to make all their complex patients drive for hours and hours). Then we get to the big buys – buyers. For Medicare, there are some committees that appear to be overwhelmingly ignorant of actual medical practice but they set baseline reimbursements for these CPT/ICD-10 combos. Those then get adjusted to account for regional costs, equity concerns, and only God knows what all else. These are normally set near the break even point on national average. Medicaid, typically, uses those rates as a baseline and then cuts them (hence why many physicians won’t take new Medicaid patients, the reimbursement rates often leave folks at a net loss). Private insurers add another layer of negotiation where they use their monopsony power to extract lower rates while, allegedly, assuring physicians of volume. The range of these negotiations can be exceedingly wide – insurers can have modifiers for quality of care (e.g. how many folks come back in the perioperative period), timeliness of care, and so on and so forth.

Okay, so somebody has haggled set a rate and we just assume that get the bog standard lap chole we have a price?

Of course not.

See that is just what has agreed, in theory, these medical services will be reimbursed at. Actual reimbursement involves a non-negligable risk on non-payment (e.g. insurance denies and the patient cannot or will not pay), delayed payment (and having to utilize credit lines to cover payroll when a large insurer has an IT glitch and doesn’t pay for two weeks is quite expensive), and of course variable legal and compliance costs. You might also be hit with clawbacks, partial payments, and a host of other payment uncertainty.

Okay, but’s lest assume a single CPT/ICD-10 setup, a prenegotiated rate that is paid on time without further processing costs, and everything is chill there. We got a price yet?

Of course not.

See all of the above is for just the surgeon’s professional fees – i.e. what is being paid for use of his hands. The OR itself? That’s a completely different bucket of money that has its own set of billing and negotiations. Facility fees make the professional fees look straight forward and simple.

But we are done now? Right?

Of course not.

See those were the professional fees for your surgeon. You also need an anesthesiologist (and/or his minions). And guess what, yep completely different bucket of money and price negotiation.

But we are done now?

Well, no. There may be different negotiations for lab fees (e.g. where does the CBC get billed), for tissue pathology, for any post-operative hospital services, and of course medications (which are billed completely differently if outpatient or inpatient) to name a few of the more common options.

There isn’t “a” price for a surgery. There are, potentially, a dozen diferent prices that can be combined in a multitude of ways with some buckets covered by one payer and other parts covered by another (and things get crazy fun when you have overlapping payers).

But aren’t there cash only surgical places with listed prices? Yes. And they have an extremely limited set of procedures with everything owned in house – i.e. a setup that is pretty much illegal to set up de novo post Obamacare.

Why does everyone have all these bizarre negotations. Why don’t you just pay the surgeon everything and then he pays the hospital, the anesthesiologist, the pathologist, etc. from that cut? Because that is an invitation for your surgeon to be charged with a crime. It is federal crime to underbill or to underbill when it comes to government monies (and in many states, private insurance monies). We are required not just to I Pencil up a price, but to make that price transparent to regulators. If a hospital wants to grant me cheaper OR time because I have reliable stream of patients, keep the OR cleaner (reducing turnaround time enough to fit another case per day in), and don’t create ancillary malpractice risk at the going rate … the hospital risks being tagged with inducement. If I negotiate a cheaper rate with the lab for my patients’ tests, it is considered prima facie evidence for kickbacks and I then have a positive burden to prove that I am not getting clandestine remuneration from the lab.

Separate, disjointed, billing through bureaucratic negotiation is legible. It is legible to the courts, to regulators, and to malpractice insurers.

But doesn’t all this massive change efficiency of care delivery?

Not that I can easily see. I have personal experience with IHS, TriCare, Kaiser, the VA, and for-profit, non-profit, and even prison care; full Beveridge like IHS is often the least efficient.

So where do cash prices come from? Outside of cash only practices, those are overwhelmingly fictions that somebody pulled out of their nether regions in a likely futile attempt to BS the counterparty to an insurance negotiation.

Why is this all so complicated:

1. Principle agent. The patient has a wildly different incentive structure than the collective payer (insurance or government) and American healthcare is insanely deferential to the patient compared to alternatives. The folks with the most direct control feel at most a small fraction of the price pain have near zero incentive to economize for anything big.
2. Taxes. The original sin of American healthcare was making insurance, rather than medical procedures themselves, tax deductible. This creates very strong incentives for people to bundle non-healthcare into insurance premiums in hard to define manners (e.g. is a health insurer offering a rebate for gym membership incentivizing exercise, allowing folks who would already have gym memberships to pay pre-tax, or just selecting for healthier patients).
3. People are terrified of physician abuse. Most folks, even other physicians, have a very hard time knowing if their physician is taking them for a ride. So they turn to something powerful to regulate physicians. But, not knowing what actually matters, these folks find it extremely hard to navigate market transactions. Healthcare would far rather have 100 unattributable deaths and 2x costs than to have 1 attributable death that regulation could avoid.
4. A complete disconnect between what folks experience for prices (e.g. my tape easily costs 10x more than department store specials, my EMR internal word processor is an order of magnitude more expensive than MSWord let alone Emacs or the like) and how medical expenses run.
5. A failure to appreciate the costs of having things on standby. We have folks ready incase a simple IR procedure perfs the vessel walls. We have countless folks handy in case your infusion leads to anaphylaxis. Or your blood transfusion moves on to TRALI. Just opening the doors typically means that we need to have a few dozen physicians and their support staff available at all times. I’ve seen a simple gallbladder turn into a massive transfusion with staging, SICU, and the whole works. I have seen STD treatment turn into a catastrophic emergency of the sort that gets Derm to come in at oh ass hundred.

None of those go away if we post prices. And a lot of people will be upset – somebody will decry us pricing differently for different patients – everyone deserves the same care at the same cost. Somebody will decry us for not pricing differently enough – people should be reward for making good decisions.

Long run, healthcare is going to get more expensive. I expect it will eventually be on part with mortgage payments (you know you live in your body 24/7). But there is an evergreen fantasy that … if only … then we could reduce prices.

You can’t. You can, maybe, make them rise more slowly, normally for harsh tradeoffs Americans won’t stand. And just about every significant intervention that really moves the price needle … is either selection (e.g. health share ministries have wildly healthier populations because they are heavily selected about drugs, promiscuity, and the rest) or given entirely back by the patient dying later. And the handful of things to do pass muster (e.g. HPV vaccination, Hep C treatment) … it becomes yet another morass of how much to pay whom.

Healthcare is not a normal market. We should stop pretending it could be one.

[ed. Hence single payer, or Mediare for All. It won't solve everything, but having the government and all its various compliance mechanisms working to cut costs can't hurt.]

***

Comment: There is plenty of data from which to compute averages and provide a published estimate against which performance can be tracked. That's what consumers of professional services do in actual free markets. Making every transaction in this sector a Persian rug bazaar involving third parties with no input from the actual consumer is not how you lower costs.

Response:

It is, however, one of the more common ways to comply with regulations, liability mitigation, and uncompetitive negotiations.

The other alternative is to vertically integrate a market under and a mono(dou)poly and put all the service lines and fee sources under one roof. This has the advantage that one entity on the provider side does have all the costs and profits on one balance sheet ... but so far it is, at best, a complete bust for lowering prices (and at worst actively raises them through local monopoly power).

There is one set of constraints on healthcare that makes this a hash. It is the nature of payments, the nature of regulations, the nature of malpractice risk, and a heavy dose of inertia.

But with no single problem we also see no hope for one singular quick fix.

If you want me to lower costs (in the short term): let me own a hospital with 50 fellow physicians, allow us malpractice liability protection provided we hit prespecified milestones (and I largely don't care what you pick as long as the traditional hospitals have to meet them too), create financial incentives for patients to economize, and allow us to charge patients more aggressive for different risk and cost profiles.

Long run, all of those will fall, but our healthcare billing system wasn't built for efficiency or even naked profit maximization. It was built for regulatory compliance and navigating the insurance premium tax exemption from WWII.

***

Comment: Wait a minute here. The reason some engineering project can't be estimated in advance is because it's hard to know how many people it will take and how long. It's because it is estimating an unknown that might take 4 years or 4 months. A SURGERY should be easier to estimate. Yes, you might cut open the patient and decide the problem is cancer and not gallstones. Or they are a woman and not a man, but the surgery isn't suddenly going to take 4 years longer.. It's not going to take 4 days longer either. Of course .... if the GOVERNMENT is involved then they might get wildly different costs. But it isn't the complex nature of surgery that makes the estimate difficult. And you might say, well finding out it's cancer means a whole new cost structure .... yes it does. But THAT given surgery shouldn't change so vastly in price because of it. The new diagnosis is an entirely new issue. My MECHANIC can figure out how to call me an give a new estimate if he's there to change the oil and finds out the engine block is cracked.

No. The problems with pricing have been CREATED by massive government regulations.

Engineering projects don't have to change workforces halfway through. I have seen a surgical procedure swap successively from IR to vascular surgery to cardiothoracic surgery to neurosurg to transplant (this did not end well for the patient).

And that is part of the thing. If your mechanic encounters a cracked engine block, he waits, orders a new one, and then recommences work at leisure. Your surgeon, is diagnosing the car, while is going 80 down the freeway, has to fix the crack (because replacement parts are generally unavailable and insanely expensive for OEM if they are) without slowing down while the engine is running, and then has to make certain that his method of repair won't compromise the running of the car.

Mind you running through different surgeons often means calling in different teams (surgical assists very often specialize de facto if not de jure). And the bills mount quickly. Last time I saw the numbers, each marginal minute of OR time works out to ~$100 of extra costs (most of which is labor). And that is excluding the cost of bumping somebody off the schedule; if you are the penultimate case of the day and the system doesn't have slack to run later into the night you might well run 80 minutes over and then force us to scrub a three hour, high cost procedure which then mucks up even more OR times the following day.

Like the OR is the hotel problem are crack. Hospitals generate massive revenue by keeping ORs in constant use (spread the overhead over more patients) and a quadrupling of OR time is not going to quadruple the cost of a surgery to the system - it will often cost far, far more than.

And there are other margins. We get a bit leery about undertaking certain, technically "elective" procedures when the SICU is too full. If we are short on anesthesia folks that can bump out other patients too. If this is not a trauma I, surgical novelty can mean burning through our blood product inventory, and if that gets bad enough that means putting the ED on diversion (in which case we are paying for a lot of ED staff who are generating no revenue).

For stuff like OR, hospital efficiency is only as good as the weakest leak and because everything is often on a tight timetable with little margin (because margin costs more money) small failures can cascade to far bigger costs.

Which, generally, is not such an issue for the engineers. After all, if work halts on building one dam, it frees up labor and resources for another.

Can we just build that into the prices? Yes. And that is what vertically integrated shops do and they average the truly horrific cases over a lot of surgeons.

But for a single surgeon's office? Yeah, no. If they quote you the full range of possible costs it will likely span three orders of magnitude for the cheap stuff.

Which is part of why separate billing works. If you go in and they find you need a different surgeon, it isn't like folks have prenegotiated every possible permutation of who else needs to take care of you. They find something wonky, they call in the cavalry, and then separate bills are generated for each.

Like I've worked with engineers to build a hospital. The number and interactions of their own unknowns was simply an order of magnitude or two lower.

***

If people want wildly cheaper healthcare they already know how to do it: don't smoke, exercise, eat not complete garbage, get married, have lots of sex, have kids, go to church, hang out in person with friends, sleep soundly with a steady schedule, get educated/earn lots of money, don't do drugs, drink no more than one standard drink a night (and like just one or two a week), don't engage in crime, get car with a bunch of safety technology, live close to work/get a remote job, don't gamble ... like all of these have good correlational data and when you do two-thirds of them you almost invariably end up having a way cheaper life course expenses (e.g. most of the above are correlated with lower odds of needing institutional memory care). Some of it is given back because you live longer ... but people know this. They just have a hard time giving up vices (i.e. things where the immediate reward is too tempting for them to hold out to get their preferred long run payout) or actually prefer the less healthy habits.

via: Marginal Revolution

[ed. What a system, eh? Everyone in the business of billing medical reimbusement is incentivized to make it as complex and opaque as possible. Every major medical procedure now risks financial catastrophe.]

Engineering the Disposable Diaper

Adventures in product design.

For the mothers of the baby boom, pediatrician Benjamin Spock’s child care handbook was a practical, confidence-boosting essential. Originally published in 1946 as The Common Sense Book of Baby and Child Care, Dr Spock’s baby book sold more than 500,000 copies in its first six months. By the time the second edition came out in 1957, with the simplified title Baby and Child Care, Dr Spock was selling a million copies a year. My mother, who was 24 when I arrived in 1960, still remembers the book’s reassuring tone.

‘You know more than you think you do’, the author told readers. ‘We know for a fact’, he wrote with medical authority, ‘that the natural loving care that kindly parents give to their children is a hundred times more valuable than their knowing how to pin a diaper on just right’.

Dr Spock went on to provide detailed instructions on the practical intricacies of parenthood, including diapers. Buy at least two dozen, he counseled, more if you aren’t washing them daily. Six dozen would cover all contingencies. With a diagram, he showed how to fold a diaper and explained how to position it on a boy versus a girl. ‘When you put in the pin’, he advised, ‘slip two fingers of the other hand between the baby and the diaper to prevent sticking him’. The book covered when to change the diapers and what to do with the dirties.

You want a covered pail partially filled with water to put used diapers in as soon as removed. If it contains soap or detergent, this helps in removing stains. Be sure the soap is well dissolved, to prevent lumps of soap from remaining in the diapers later. When you remove a soiled diaper, scrape the movement off into the toilet with a knife, or rinse it by holding it in the toilet while you flush it (hold tight).

You wash the diapers with mild soap or mild detergent in [the] washing machine or washtub (dissolve the soap well first), and rinse 2 or 3 or 4 times. The number of rinsings depends on how soon the water gets clear and on how delicate the baby’s skin is. If your baby’s skin isn’t sensitive, 2 rinsings may be enough.

On this subject, the 1957 edition contains two telling differences from the original. In 1946, Dr Spock recommended the knife method to those without flush toilets. And starting with the second edition, he advised new parents to buy an automatic washer and dryer if they could possibly afford them. ‘They save hours of work each week, and precious energy’, he wrote. ‘Energy’ in this case referred not to electricity or gas but to maternal stamina.

Disposable diapers did exist, but they accounted for a mere one percent of US diaper changes. They were expensive, specialty products and not that great. ‘The full-sized ones are rather bulky’, noted Dr Spock. ‘The small ones that fit into a waterproof cover do not absorb as much urine as a cloth diaper and do not retain a bowel movement as well’. Disposables were mostly used for travel, when washing diapers wasn’t an option.

But even as the second edition of Baby and Child Care was hitting bookstores and supermarket racks, change was afoot. After buying Charmin Paper Company in 1957, Procter & Gamble began looking for ideas for new paper products.

Motivated by the less pleasant aspects of spending time with his new grandchild, the company’s director of exploratory development, Victor Mills, suggested disposable diapers. After analyzing existing products and conducting consumer research, P&G created a dedicated diaper research group.

The research this group conducted, like that of its successors and competitors, wasn’t glamorous. It didn’t advance basic science. It wasn’t even an obvious route to profit. (One percent of the market!) It was a high-stakes gamble that required solving difficult engineering problems. How that happened represents the kind of hidden progress that leads to everyday abundance.

P&G’s first design flopped. Tested in the extreme heat of a Dallas summer, the pleated absorbent pad with plastic pants made babies miserable and left them with heat rashes. Starting over, the group had a one piece diaper ready for testing in March 1959. With an improved rayon moisture barrier between the baby and the absorbent tissue wadding, the new diaper was softer and more comfortable. An initial test of 37,000 hand-assembled prototypes went well, with about two thirds of the parents deeming the disposables as good or better than cloth. The next step was mass production.

Designing one well-functioning disposable was hard enough. Turning out hundreds a minute was practically impossible. ‘I think it was the most complex production operation the company had ever faced’, an engineer recalled.

There was no standard equipment. We had to design the entire production line from the ground up. It seemed a simple task to take three sheets of material – plastic back sheet, absorbent wadding, and water repellent top sheet – fold them in a zigzag pattern and glue them together. But glue applicators dripped glue. The wadding generated dust. Together they formed sticky balls and smears which fouled the equipment. The machinery could run only a few minutes before having to be shut down and cleaned.

Eventually, the diaper team mastered the process. In December 1961, Pampers went on the market in Peoria, Illinois. Once again, the test failed.

This time mothers liked the diapers. But the price was way too high for a single use item: ten cents a diaper, equivalent to about one dollar today. By contrast, diaper delivery services, which served about five percent of the market, charged no more than five cents a diaper. Home laundry costs ran to one or two cents.

Lowering the price of a diaper required much larger volumes. Aiming at about six cents a diaper, P&G engineers spent several years developing what Harvard Business School’s Michael E. Porter described as ‘a highly sophisticated block-long, continuous-process machine that could assemble diapers at speeds of up to a remarkable 400 a minute’. After successfully testing Pampers at 5.5 cents each, P&G began a national rollout in 1966. By 1973, disposables accounted for 42 percent of the US diaper market. [...]

The success of Pampers drew competitors into the growing market. ‘Any diaper maker that carved out a modest market share against Procter & Gamble could expect sales to triple as a result of sheer market growth’, write business historians Thomas Heinrich and Bob Batchelor in Kotex, Kleenex, Huggies, a history of Kimberly-Clark. But there was a catch. The bulky diapers took up so much space on shelves that stores rarely stocked more than two brands, plus maybe a discounted private label. Second place meant profits, third place disaster.

by Virginia Postrel, Works in Progress | Read more:
Image: A nurse demonstrating to young immigrant mothers how to diaper their babies: Israel Government (1950)

Into the Wood Chipper

The destruction of USAID was just as dumb as it seemed

On February 5, 2025, after USAID’s name had been taken off the building, after most of its staff had seemingly been placed on leave (it was hard to be sure—HR couldn’t confirm because they were also largely locked out of the system), Nicholas Enrich was called in to justify the agency’s global health programming to the Trump administration’s newly-appointed USAID leadership.

According to Enrich, he spoke for about five minutes about USAID’s lifesaving health work: diagnosis and treating HIV and malaria, immunizing children, responding to emerging pandemics. His presentation was met by silence, which senior official Ken Jackson eventually broke. “Wow, there really is so much that USAID does that we never knew,” Jackson said.

Joel Borkert, USAID’s Trump-appointed acting chief of staff, agreed: “I had no idea you did all this. As a Republican, when I think of what USAID does in global health, I assumed it was just, you know, abortions.”

Adam Korzeniewski, the White House liaison to USAID, was similarly enlightened, and he had an idea. To help raise attention to the importance of programs to fight drug-resistant tuberculosis, “he suggested that [they] draft a simple, ‘Barney-style’ set of slides to help the political leadership grasp the dangers, referring to the purple dinosaur of children’s television.”

Korzeniewski acknowledged that most of the relevant officials weren’t “health people,” but he didn’t think that applied to him—he had recently read a book on smallpox. Enrich writes that Korzeniewski had another idea, too:

“One thing I thought of while you were talking,” he added, gesticulating wildly with his hands to conjure the image in his mind. “If you can make one of those maps like they have in Outbreak, where it shows the red growing over time as the disease spreads? You know, like the zombie apocalypse? That would be great, very effective.”

Much of Nicholas Enrich’s new book proceeds like this, describing a process so surreal that it verges on the comical until you remember that millions of lives were in the balance. Into the Wood Chipper: A Whisteblower’s Account of How the Trump Administration Shredded USAID follows the 42-day spell that took Enrich from a relatively anonymous USAID worker to its highest-ranking health official to the author of a widely-reported memo detailing the deadly consequences of the destruction of USAID.

Into the Wood Chipper occupies the somewhat unique genre of civil service thriller, only to then verge into horror. More than anything, it was a 206-page reminder that what happened was so, so murderously dumb.

by Tim Hirschel-Burns, Together But Apart |  Read more:

Image: uncredited

[ed. See also: Everyone is misunderstanding what happened to USAID (TBA):]

***

The problem is that the development sector’s reckoning with the destruction of USAID has been largely unmoored from what actually happened. The post-mortems have tended to follow a similar recipe: a dash of lamentation and a spoonful of self-flagellation, topped with one cup of the author’s pre-existing policy preferences—all of which bear a tenuous relationship to what actually doomed USAID...

When Trump took office and DOGE went into USAID, even they didn’t plan on destroying it. But two weeks later, USAID was functionally dead. In the end, the administration terminated 83% of USAID projects, shuttered USAID as an independent agency, and kept on just 300 of USAID’s over 10,000 staff in the State Department.

Why Your Job’s Complexity Level May Affect Your Risk of Dementia

Getting an education is important for a lot of reasons, but there might be one reason you haven’t heard — it could lower your risk of dementia later in life. Decades of research have supported this claim, with one study showing that each additional year of formal education lowers the risk of Alzheimer’s disease or other types of dementia by 7 percent.

Now, a growing body of evidence suggests that the jobs we hold throughout our lives may matter just as much or more than years of education. Having a job that involves high levels of decision-making or creativity, rather than repetitive or manual tasks, could help keep the mind sharp and active.

“Many studies suggest that, if people are working in complex jobs during their lifetime, they have a lower likelihood of developing dementia in later life,” said Jinshil Hyun, assistant professor of neurology at Albert Einstein College of Medicine.

Roles like managers, teachers, lawyers and doctors are considered high complexity jobs, while clerical, transportation and assembly line work have lower complexity. The findings are consistent with the idea that taking part in mentally stimulating activities throughout the lifespan can help preserve late-life brain health and boost cognitive reserve — the brain’s ability to cope with age- or disease-related changes.

But don’t worry if your job doesn’t meet the criteria — there are other things that you can do to improve your cognitive reserve, such as reading, socializing and volunteering.

Why work might be linked to dementia risk

“We spend most of our day in work, at least eight hours a day. So that’s like, a third of our time engaged in work, sometimes more,” said Naaheed Mukadam, professor of psychiatry at University College London. “That’s a large part of what our brain is engaged in and therefore will have a large contributory effect on cognitive reserve development.”

In a recent study, Mukadam and her colleagues investigated which factors could be influencing education’s protective effect against dementia. Their analysis included 384,284 participants and took note of health behaviors like drinking, smoking and exercise; medical conditions like hypertension and diabetes; occupational complexity; and income. The results uncovered that occupational complexity is actually the biggest reason more education tends to lower your risk of dementia, accounting for more than 70 percent of that link.

“We found that occupational complexity explained the biggest proportion of that relationship between education and dementia,” she said. “People who have more education tend to get into better paid, more complex jobs. Then, the benefits for their physical and cognitive health compound in that way.”

Multiple studies have found that those with higher income have a lower risk of dementia, and the researchers speculate that job complexity likely plays a major role in that relationship as well.

Similarly, Hyun and her colleagues found in a 2021 study that occupational complexity is predictive of later-life dementia, independent of education. They looked at the effects on dementia-free survival time, or how many years a person lived before being diagnosed with dementia, in 10,195 participants from six countries. As expected, high school graduates had a 26 percent increase in dementia-free survival time compared to people who only completed middle school or less.

After controlling for education, high occupational complexity, compared to low occupational complexity, was associated with a 19 percent increase in dementia-free survival time. Hyun speculates that the greater mental stimulation of a complex job builds cognitive reserve, which helps people resist cognitive decline and stay mentally sharp for longer, even in the presence of harmful plaques seen in Alzheimer’s-affected brains.

“The cognitive reserve hypothesis suggests that, if people are doing cognitively enriching activities, then their brain has a more efficient network,” Hyun said.

by Meeri Kim, The Washington Post/Seattle Times |  Read more:

Image: iStock

[ed. Or just develop a life long love of learning. Eric Hoffer would be a good example (longshoreman/philosopher). What'll happen when more people offload their thinking to an AI assistant?]

Intraventricular CARv3-TEAM-E T Cells in Recurrent Glioblastoma

In this first-in-human, investigator-initiated, open-label study, three participants with recurrent glioblastoma were treated with CARv3-TEAM-E T cells, which are chimeric antigen receptor (CAR) T cells engineered to target the epidermal growth factor receptor (EGFR) variant III tumor-specific antigen, as well as the wild-type EGFR protein, through secretion of a T-cell–engaging antibody molecule (TEAM). Treatment with CARv3-TEAM-E T cells did not result in adverse events greater than grade 3 or dose-limiting toxic effects. Radiographic tumor regression was dramatic and rapid, occurring within days after receipt of a single intraventricular infusion, but the responses were transient in two of the three participants. (Funded by Gateway for Cancer Research and others; INCIPIENT ClinicalTrials.gov number, NCT05660369.)

***

Glioblastoma is the most aggressive primary brain tumor, and the prognosis for recurrent disease is exceedingly poor with no effective treatment options. Chimeric antigen receptor (CAR) T cells represent a promising approach to cancer because of their proven efficacy against refractory lymphoid malignant neoplasms, for which they have become the standard of care. However, the use of CAR T cells in solid tumors such as glioblastomas has been limited to date, largely owing to the challenge in targeting a single antigen in a heterogeneous disease and to immunosuppressive mechanisms associated with the tumor microenvironment. 

In a previous clinical trial, we found that peripheral infusion of epidermal growth factor receptor (EGFR) variant III–specific CAR T cells (CART-EGFRvIII) safely mediated on-target effects in patients with glioblastoma. Despite this activity, no radiographic responses were observed, and recurrent tumor cells expressed wildtype EGFR protein and showed heavy intratumoral infiltration with suppressive regulatory T cells. To address these barriers, we developed an engineered T-cell product (CARv3-TEAM-E) that targets EGFRvIII through a second-generation CAR while also secreting T-cell–engaging antibody molecules (TEAMs) against wildtype EGFR, which is not expressed in the normal brain but is nearly always expressed in glioblastoma. We found in preclinical models that TEAMs secreted by CAR T cells act locally at the site where cognate antigen is engaged by the CAR T cells in the treatment of heterogeneous tumors. We also found in vitro that these molecules have the capacity to redirect even regulatory T cells against tumors. On the basis of these data, we initiated a first-in-human, phase 1 clinical study to evaluate the safety of CARv3-TEAM-E T cells in patients with recurrent or newly diagnosed glioblastoma. Here, we report the findings from a prespecified interim analysis involving the first three participants treated with this approach. [...]

Discussion

This study shows that antitumor CAR-mediated responses can be rapidly obtained in patients with glioblastoma, even in those with advanced, intraparenchymal cerebral disease. This finding contrasts with a previous report of a complete response that was observed in a patient with recurrent leptomeningeal disease who received treatment with 16 intracranial infusions of monospecific interleukin-13 receptor alpha 2 CAR T cells. It was hypothesized by the investigators of that study that the involvement of glioblastoma in the leptomeninges may have rendered the disease more responsive to intraventricular therapy. Our experience in the current study suggests that even a single dose of intraventricularly administered living drugs such as CAR T cells also have the capacity to access and mediate activity against infiltrative, parenchymal glioblastoma.

by Bryan D. Choi, M.D., Ph.D., Elizabeth R. Gerstner, M.D., Matthew J. Frigault, M.D., Mark B. Leick, M.D., Christopher W. Mount, M.D., Ph.D., Leonora Balaj, Ph.D., Sarah Nikiforow, M.D., Ph.D., Bob S. Carter, M.D., Ph.D., William T. Curry, M.D., Kathleen Gallagher, Ph.D., and Marcela V. Maus, M.D., Ph.D. NIH, National Center for Biotechnology Information |   Read more:

Image: via

[ed. Only three patients (so far) and it appears sustained treatments are needed to prevent recurrence. But still, pretty interesting.]

The Last Useful Man

About halfway through Mission: Impossible — The Final Reckoning, Tom Cruise goes for a run on a treadmill. The treadmill is on the USS Ohio, a submarine manned exclusively by implausibly attractive people. One of those people is not who they seem: a cultist, radicalized by the Entity, the film’s AI antagonist. The cultist sneaks up behind Cruise and lunges with a knife. Things look dicey for a moment — until Cruise gains some distance and kicks him repeatedly in the head. While doing so, he imparts a few words of wisdom: “You spend too much time on the internet.”

What divides the heroes and villains in Final Reckoning is simple: the villains have to Google things, and the heroes do not. There are three bad guys, more or less. First, the Entity, a rogue AI halfway through its plan for global domination. Second, Gabriel, the Entity’s meat puppet. Third, a gang of surprisingly likable Russians who take Cruise’s team hostage in a house in Alaska. What unites the villains isn’t malice so much as it is uselessness. I mean that precisely. They are often effective, even successful. But never useful. [...]

This division between characters with embodied knowledge and those without runs through all of Cruise’s recent work. His own impossible mission is to teach the value of physical competence: not just knowing things, but knowing how to do them. In Final Reckoning, this idea finds its clearest form. [...]

Like Forster, Cruise and his long-time collaborator Christopher McQuarrie invent machines to dramatize the age they live in. Forster gave us the Machine; McQuarrie, the Entity. But unlike Forster, their imagination of technology is not apocalyptic but diagnostic — they aren’t warning us of the machine age so much as asking what it demands of us, and what it reveals.

This brings us to what looks, at first glance, like a paradox: How does a franchise so lovingly built on disguises, gadgets, and inventions of all kinds — from the eye-tracking projector that gets Cruise into the Kremlin to the single suction glove that lets him cling to the Burj Khalifa — end with a villain made of pure technology?

If you asked Cruise, his answer would be simple: technology is good when it roots you in your body and bad when it lets you forget you have one. That’s why Final Reckoning, for all its AI villainy and suspicion of the terminally-online, still treats technology with a near-Romantic sensibility. Hand-soldered pen drives, aging aircraft carriers, and vintage biplanes carry Cruise and his team on their mission to save the world. At times subtlety disappears altogether; the film’s most inviting location is a candle-lit Arctic hideout filled with analogue comforts: old books and gramophones, telescopes and soldering tools.

The same ideas return — turned up to eleven — in Cruise and McQuarrie’s two other collaborations this decade outside the Mission: Impossible franchise. The first, Edge of Tomorrow, in which Cruise relives the same day on repeat until he generates enough embodied knowledge to defeat an autonomous alien race, is, even for the purposes of this essay, too on the nose, so I’ll focus instead on Top Gun: Maverick.

The film opens with Cruise test-piloting an experimental stealth aircraft in a last-ditch attempt to save the program from cancellation by the “drone ranger,” an admiral who wants the budget for his autonomous fleet. For the program to survive, Cruise needs to hit Mach 10: a speed no vehicle has ever reached. As the team watches on, he delivers the impossible. Gauzy wisps of supersonic air stream across the cockpit windows as Maverick stares out into the black of space. He whispers softly to his dead best friend, “Talk to me, Goose.”

Soon afterwards, Maverick is sent back to Top Gun to train a new generation of pilots. He begins his first lesson holding up the flight manual for the F-18, which makes the Riverside Chaucer look like a novella, before throwing it in the bin. “I assume you know this book inside and out. So does your enemy.” What matters instead is the knowledge that can’t be written down: the things his students already know by instinct, but cannot yet express  “Today we’ll start with only what you think you know.”

The quest to ‘“know more than we can tell,”’ as Michael Polanyi put it, drives the rest of the film. The pilots even have their own version of the phrase, a near-religious catechism recited at almost every decisive moment: “Don’t think. Just do.”

Beyond the screen, the same principle applies. In the Mission: Impossible franchise, filming begins with no plot or script, only a commitment to figuring it out in the process. It’s most evident in each film’s tentpole action sequences, where the line between Cruise the actor and Cruise the stuntman blurs beyond recognition.

The art critic Robert Hughes once wrote of his love for “the spectacle of skill” — the thrill of watching an expert at work, whatever the discipline. Nowhere is this more evident than in Cruise’s increasingly daring plane sequences. In Mission Impossible: Rogue Nation, Cruise clings to a real Airbus A400M as it lifts off from an airfield in Lincolnshire. He sprints across the field, in that inimitable Tom Cruise style, mounts the wing with practiced ease, and seats himself by the cargo door. The plane taxis. So far, so cool. Then it lifts off. The perfect hair vanishes, blown back and forwards, alternating second by second between old skeleton and boy with bowl cut. His clothes are shapeless and billowing, pulled off him by the force of the air.

This is no country for sprezzatura, nor the embodiment preached by the wellness industry with its vocabulary of “balance” and “equilibrium.” Here, we are meant to feel the effort. To know yourself is to know your limits, and so push your body to the edge of failure. When they are about to perform stunts, Cruise often briefs his team with an unusual mantra: ‘Don’t be safe, be competent.”

At the end of Final Reckoning, Cruise plummets through the sky as his parachute burns to cinders above him. To film it, the stunt team soaked a parachute in flammable liquid, flew him to altitude in a helicopter, and pushed him out as it ignited. He did this 19 times. When he asked to go again, the stunt coordinator told him there were no parachutes left. This was a lie. McQuarrie was more direct: “You’re done. Do not anger the gods.”

It’s interesting to see this return to embodiment and strange to find myself drawn to it. Like many default clever people, I’d long paid lip service to Merleau-Ponty and his ilk while living as a dualist; my brain was the moneymaker, my body just along for the ride. It was only after having children that I began to understand what it meant to inhabit a body rather than simply use one.

In an essay for Granta earlier this year, the writer Saba Sams contrasted her son’s love of leaping from benches and walls with her own unease: “For them, the body is not a constraint, is not a ticking clock, is not something to be moulded or hidden. The body is the window to movement, and movement is a window to joy.”

Sams captures something larger. This renewed fascination with embodiment isn’t spontaneous, it’s a reaction to technologies so powerful and frictionless they’re impossible to ignore. Even the most grounded among us now move through the world not through our bodies but through screens, which is why so many make the negative case for technology, urging us, thankfully without a Cruise-style kick to the head, to spend less time on the internet.

What Cruise gives us is the positive case: not just resistance to disembodiment but a reminder of what is beautiful about being physical in the first place. The skilled things bodies can do are inherently satisfying. They can be thrilling, reassuring, even a little terrifying. But, as David Foster Wallace put it in his essay on Roger Federer:

The human beauty we’re talking about here is beauty of a particular type; it might be called kinetic beauty. Its power and appeal are universal. It has nothing to do with sex or cultural norms. What it seems to have to do with, really, is human beings’ reconciliation with the fact of having a body.

That’s the mission, if we choose to accept it. The target is not the recent bugbear of AI, but instead the more gentle conditions of modernity. When we use Google Maps instead of a printed atlas, or when CGI is used to sell a stunt instead of the performers doing it themselves, something is lost. It’s why the focus on AI can sometimes be misguided. It’s not so much a revolution, it’s simply the next step on the ladder of disembodiment: another in a long line of technologies to make humans a little less self-reliant. Why learn, if you can ask?

In the final biplane sequence, we watch Cruise commandeer a plane, fly it to another, board that plane midair, and take control of it — a feat so exhausting it beggars belief. Gabriel, the villain, in order to survive his defeat, needs only do something a hundredth as difficult: jump from the plane and deploy a parachute. He laughs. This is easy. But he doesn’t know the complexities of leaving a biplane with a parachute — the correct moment to release, the parts to steer clear from. He’s never bothered to learn. He frees himself, clips the rudder, cracks his skull open, and dies.

Here we see the real villain: not intelligence, but convenience. The mission so often feels impossible because we keep trying to do things without effort. Cruise’s answer is simple: Stop. Remember your body. Sometimes, it’s better to take the hard way.

Final Reckoning’s closing scene presents us with two intelligences and two bodies. One is Cruise, a 62-year-old body who we’ve seen, for the last two hours, run fast, dive deep, and hang from planes. The other is the Entity, trapped in a glorified USB stick: a golden nugget incapable of anything other than being flushed down a toilet.

One still moves. The other never could.

by Aled Maclean-Jones, The Metropolictan Review | Read more:
Image: Getty

Millions of Americans Are Going Uninsured Following Expiration of ACA Subsidies

Nearly one in 10 people who had Affordable Care Act plans last year dropped health insurance altogether, after premium costs rose sharply because of the expiration of federal subsidies, according to a new survey.

Most of those who remained in ACA plans reported larger out-of-pocket healthcare expenses in the form of higher copays, coinsurance or deductibles, according to the survey from health-research nonprofit KFF. About one-sixth of those who still have ACA coverage, or 17%, weren’t sure they would be able to afford their new premium payments for the entire year, indicating more people might drop insurance as the year goes on.

The survey is the broadest look yet at the fallout from the end of enhanced ACA subsidies, which lapsed at the start of this year, increasing premium bills for millions of enrollees. The higher healthcare costs have forced many ACA policyholders to make hard choices at a time when grocery and gas prices are also rising.

In February and early March, KFF polled 1,117 people who had ACA plans in 2025 and found that the most common reason people cited for dropping insurance was cost. Last year, more than 20 million people had ACA policies.

“Not only is there significant coverage loss, but there could be more to come,” said Cynthia Cox, a senior vice president at KFF. She said the survey results were “about on target” compared to what had been expected.

Of those surveyed, 69% still have ACA policies this year. Beyond the 9% who said they are uninsured, 22% of respondents now have some other type of coverage, such as Medicare or employer-sponsored insurance.

Kelly Rose, 59 years old, who lives near Orlando, Fla., became uninsured this year because she couldn’t pay the roughly $1,700 monthly bill to keep the ACA plan she had in 2025. “It’s more than my mortgage,” she said. The cost is a huge jump compared to 2025, when she got help from a subsidy, she said.

Though her job at a bank offers health insurance, she said she missed the enrollment window in the fall because she had planned to keep the ACA plan, not realizing how much it would cost.

Rose is now turning to a Canadian pharmacy to get her asthma medication, which costs $800 a month in the U.S. [...]

The ACA changes, which were the subject of a political battle that led to the longest-ever government shutdown last year, are likely to become a flashpoint again in this fall’s midterm elections. Democrats have blamed Republicans for failing to renew the expanded subsidies, and for growing healthcare costs. Republicans have argued the ACA is flawed and needs to be changed.

by Anna Wilde Mathews, Wall Street Journal |  Read more:

Image: Nate Ryan for WSJ
[ed. Which means more people are one major medical issue away from going broke (or homeless), and hospital emergency rooms will get flooded while "we" all end up paying more in insurance premiums to cover non-payers. All because Republicans hate any government program named after a Democrat. Insane. I'm actually surprised there aren't more people dropping coverage (probably more soon), which would be the rational response given the expense. See also: How New Mexico Became an Obamacare Success Story (NYT). Hint: state subsidies.]

America and Public Disorder, and "The Kill Line"

Two weeks ago, on the blue line to O’Hare, my car had two men smoking joints, a broken woman, her eyes dilated and blank, sitting in a nest of filthy bags smelling of sewage, and a man barking into the void, shirtless, who was washing himself with flour tortillas, which would disintegrate, littering the subway floor, before he took out another and began the same process. This didn't shock me, or anyone else around me, since I'd seen some variation of this dystopian scene on every Chicago metro line I'd ridden, every pedestrian walkway I'd passed through, and on most street corners.

Three weeks ago, in Duluth, half the riders on every bus I took were mentally tortured and/or intoxicated. The downtown Starbucks, pedestrian malls, and shuttered doorways of vacated buildings all housed broken people. Same in Indianapolis, El Paso, New York City, Jacksonville, LA, Phoenix, and almost every community I’ve been to in the U.S., save for those gated by wealth.

An epidemic of mental illness and/or addiction plays out in the U.S. in public, with our streets, buses, parking lots, McDonald’s, parks, and Starbucks as ad hoc institutions for the broken, addicted, and tortured.That is not the case for the rest of the world, including where I am now, Seoul. My train from the airport was spotless, and so is the ten-mile river park I walk each day here, which given that large parts of it are beneath roadways is especially impressive. In the U.S. it would have impromptu homes of tents, cardboard, and tarps, smell of urine, and the exercise spots that dot its length probably couldn’t exist because of a fear of being vandalized.

You can learn more about the U.S. by traveling overseas and comparing, and five years of that has taught me we accept far too much public disorder.

We are the world’s richest country, and yet our buses, parking lots, and city streets are filthy, chaotic, and threatening. Antisocial and abnormal behavior, open addiction, and mentally tortured people are common in almost every community regardless of size.

I’ve written about this many times before, because it is so striking, and it has widespread consequences, beyond the obvious moral judgement that a society should simply not be this way.

It’s a primary reason why we shy away from dense walkable spaces and instead move towards suburban sprawl. People in the U.S. don’t respect, trust, or want to be around other random citizens, out of fear and disgust. Japanese/European style urbanism—density, fantastic public transport, mixed-use zoning, that so many American tourists admire—can't happen here because there is a fine line between vibrant streets and squalid ones, and that line is public trust. The U.S. is on the wrong side of it. Simply put, nobody wants to be accosted by a stranger, no matter how infrequent, and until that risk is close to nil, people will continue edging towards isolated living.

It is why we “can’t have nice things” because we have to construct our infrastructure to be asshole-proof, and so we don’t build anything or build with a fortress mentality, stripping our public spaces down to the austere and utilitarian, emptying them of anything that can be vandalized.

The canonical example of this is La Sombrita, the laughably expensive Los Angeles “bus stop” that was a single pole to provide shade and security lighting, but did neither. La Sombrita exists precisely because it doesn’t do anything, which is the end result of a decades-long process of defensive construction. If you build a nice bus stop it is either immediately broken or turned into shelters for the destitute, and so you stop building those.

Another nice thing we don’t have in the U.S. is public restrooms. We don’t have them out of a justified fear of abuse, which is the same reason many Starbucks lock their restrooms. McDonald’s does this as well, depending on the location, and also even strips them of mirrors in the especially bad communities, to discourage people from using them for an hour-long morning toilet, as well as breaking the mirrors just for the hell of it.

This lack of public restrooms became an issue on Twitter when the latest round of debate about disorder in the U.S. was kicked off when a tweeter noted how offensive it was to have seen someone urinating in a crowded New York subway car.

This debate brought out a lot of absurd arguments, mostly from those trying to shrug it off or suggest it was simply the price of living in a big city.

No, the rest of the world doesn’t tolerate the amount of antisocial behavior we in the U.S. do. If someone were to piss on a subway anywhere else in the world, and very very few ever would want to (more on why below), they are removed from society for a period of time.

We however let people who aren’t mentally competent continue to engage in self-destructive and aberrant behavior without removing them, which consequently ruins it for everyone else, except those wealthy enough to build their own private islands of comfort.

Someone peeing on the subway is not of sound mind, and it isn’t normal behavior by any measure. It’s a sign of distress that should cause an intervention—by police, social workers, whoever—that mandates them into an institution for a period of time, until they regain sanity and stability. For someone actively psychotic —civil commitment to psychiatric hospital. For violent individuals refusing treatment—secure prison facilities with mandatory programs. For severe addiction—medical detox and residential treatment without the ability to walk away.

They should not be allowed to do whatever they want because they cannot control themselves enough to have that freedom. Someone shouting at strangers, someone washing themselves with flour tortillas, someone punching at the air voicing threats shouldn’t, for their own safety and others, be out roaming the streets. [...]

I’ve been very careful up to now not to use the word homeless, because it’s become an overly broad category that covers families in motels with Section 8 vouchers, people sleeping on friends’ couches until they can get back on their feet, mothers with children in long-term shelters, and then those who live in tents under bridges or sleep in a soiled sleeping bag.

Eighty-five percent (or so) of those in this broad category are not causing problems. They are, like most everyone else, doing their best to get by and better themselves. Sure, they have more complicated and chaotic lives than most, but they try to play by the rules as best they can.

Our problems in public spaces come from the fifteen percent or so who fall into the last group—the stubbornly intransigent—which are people who have options for housing but turn them down for a variety of reasons, some driven by mental demons, some by an overwhelming desire to always be on drugs, some simply out of preference to be alone. Others in this category have been ejected from housing because of continual violent and threatening behavior.

They are not, by almost any metric, of sound mind, and shouldn’t be granted the full privileges other citizens have.

The cover photo is John, and he is in this category. He had set himself on fire the day before I met him, freebasing a perc 30, and refused to go to the hospital because he didn’t want to lose his favorite spot behind the garbage bin, since it was only a block away from dealers and perfect to piss in. He had a government room he didn’t use because catching on fire (something he did every now and then) set off smoke alarms. He also thought it was cursed and monitored by the same people who had held him captive on an island in the middle of the Pacific—an island he escaped from three months before by swimming the four hundred miles. He showed me an arm, covered with burns, that he claimed was where a shark had bit him.

John should be mandated into a prison, a mental institution, or a rehab clinic, until he is competent enough to be on his own, not out on the streets in mental and physical pain, setting himself on fire. It is as simple as that, although I understand a change like this comes with additional nuanced policy debate. As for costs, it is more a question of redirecting what we spend rather than finding additional money, because we already spend an immense amount on this problem—the New York City budget for homeless services is four billion—without 'solving' it.

Even if you put aside the destruction this type of behavior has done to broader society, and your concerns are only focused on the health and welfare of the stubbornly intransigent, then our current system is still deeply wrong. We are not providing them justice by allowing them to choose a public display of mental misery, where the self harm they can do is far greater than when being monitored.

Beneath all this discussion is the additional question of why we in the U.S. have so many mentally unstable people, why so many are addicted to drugs, why so many people are OK with doing shocking things.

by Chris Arnade, Walks the World | Read more:
Images: X/uncredited

[ed. We've lost the plot. Or not. Maybe this is just an accurate reflection of this country's priorities over the last 50 years or so. Even worse, with AI just around the corner, it's going to get a lot worse unless our government starts working for its people again (and our people start working for our country again, beginning with acknowledging their own civic duties and responsibilities that go beyond simply paying taxes, gaming the system, and trying to make as much money as possible). From the comments:]

***

One of the things travel does best is remove the normalization filter we build at home. When you move between countries long enough, patterns that once felt “just how things are” start to look like choices societies have made - or failed to make.

What strikes me in pieces like this is not the comparison itself, but the discomfort it creates. Clean transit systems, safe public spaces, and functioning streets aren’t cultural miracles; they’re outcomes of priorities, incentives, and sustained public decisions. When those systems break down, the result isn’t abstract policy failure - it’s visible human suffering playing out in the most ordinary places.

Travel doesn’t just show us new landscapes. It quietly exposes which problems we’ve decided to tolerate.

***

[ed. See also: The Kill Line: Why China Is Suddenly Obsessed With American Poverty (NYT).]

Chinese commentators are talking a lot these days about poverty in the United States, claiming China’s superiority by appropriating an evocative phrase from video game culture.

The phrase, “kill line,” is used in gaming to mark the point where the condition of opposing players has so deteriorated that they can be killed by one shot. Now, it has become a persistent metaphor in Communist Party propaganda.

“Kill line” has been used repeatedly on social media and commentary sites, as well as news outlets linked to the state. It has gained traction in China to depict the horror of American poverty — a fatal threshold beyond which recovery to a better life becomes impossible. The phrase is used as a metaphor to encompass homelessness, debt, addiction and economic insecurity. In its official use, the “kill line” hovers over the heads of Americans but is something Chinese people don’t have to fear. [...]

The power is in the simplicity of what it describes: an abrupt threshold where misery begins and a happy life is irreversibly lost. The narrative is meant to offer China’s people emotional relief while attempting to deflect criticism of its leaders.

The worse things look across the Pacific, the logic of the propaganda goes, the more tolerable present struggles become. [...]

The fact is that societal inequality is a problem in both China and the United States. And the American economy no doubt leaves many people in fragile positions. The causes are complex.

Yet in China, poverty is experienced and perceived differently. In most Chinese cities, street begging and visible homelessness are tightly managed, making them far less prominent in daily life. Many urban residents encounter such scenes only through foreign reporting, rebroadcast by Chinese state media, about the United States and other places. [...]

When I was growing up in China in the early 1980s, my family subscribed to China Children’s News, which ran a weekly column with a simple slogan: “Socialism is good; capitalism is bad.” It described seniors in American cities scavenging for food, and homeless people freezing to death. Those stories were not invented, but they lacked context and were presented as the dominant experiences in American society. Much of Chinese society was still closed off from the world, and reliable information was scarce.

That many people accepted such narratives was hardly surprising. What’s striking is that similar portrayals continue to resonate today, when access to information is relatively much greater despite state control.

The formula is simple: magnify foreign suffering to deflect from domestic problems. That approach is taking shape today around the “kill line” metaphor.

The phrase is believed to have been first popularized in this new context on the Bilibili video platform in early November by a user known as Squid King. In a five-hour video, he stitched together what he claimed were firsthand encounters of poverty from time he spent in the United States. His video used scenes of children knocking on doors on a cold Halloween night asking for food, delivery workers suffering from hunger because of their meager wages and injured laborers discharged from hospitals because they could not pay.

The scenes were presented not as isolated cases but as evidence of a system: Above the “kill line,” life continues; below it, society stops treating people as human.

The narrative spread beyond the Squid King video, and many people online repeated his anecdotes. Essays on the nationalist news site Guancha and China’s biggest social media platform, WeChat, described the “kill line” as the “real operating logic” of American capitalism. [...]

In many of the commentaries, anecdotes about Americans experiencing abrupt financial crises are followed by comparisons with China. Universal basic health care, minimum subsistence guarantees and poverty alleviation campaigns are cited as evidence that China does not permit anyone to fall into sudden distress.

“China’s system will not allow a person to be ‘killed’ by a single misfortune,” one commentary from a provincial propaganda department states.

Many readers expressed shock at American poverty and gratitude for China’s system. “At least we have a safety net,” said one commenter...

“A topic does not gain traction simply because people are foolish,” one person wrote on WeChat. “Often, it spreads because confronting reality is harder.”

by Li Yuan, NY Times |  Read more:

Image: Doris Liou

Please Hold

She called 911 for an ambulance. She got a nightmare instead.

When Pamela Hogan phoned 911 from her Seattle apartment, she was suffering from knee pain so intense she couldn’t stand up. She had been trapped in her bed all day, unable to eat, drink or get to the bathroom. Worried and alone, Hogan thought an ambulance would come quickly and take her to the hospital.

She was mistaken.

Seattle no longer is capping ambulance wait times for certain 911 patients, tracking those waits or penalizing its ambulance contractor when they run long.

Rather than send Hogan help right away, the Fire Department routed her to a nurse in Texas who determined her crisis didn’t need immediate attention.

So the 71-year-old, a retired executive assistant who loved cooking casseroles, watching “Judge Judy” and listening to The Pointer Sisters, waited one hour for a nurse-ordered ambulance, according to call recordings and court documents.

Two hours. Three hours. Four hours, phoning 911 back several times and telling the Fire Department about a heart condition. Ten hours.

By the time an ambulance arrived at Hogan’s building, it was the middle of the night and she wasn’t answering her phone. The ambulance left without her.

Weeks later, her body was found decomposing on the floor of her bedroom.

It’s not clear Hogan’s wait is what killed her, but her estate has sued and her experience raises questions about Seattle’s relationship with its for-profit ambulance contractor, American Medical Response, which also provides the city’s 911 nurse line.

“More checks and balances and accountability need to happen,” said Josephine Ensign, a professor emeritus at the University of Washington School of Nursing who called Hogan’s case concerning and upsetting. “Seattle can do better.”

Seattle and AMR have denied the lawsuit’s wrongful death allegations and say the nurse line is generally working as intended. They say it’s reducing strain on hospitals and ambulances by diverting low-level patients to more appropriate care.

But most Seattle callers triaged by the nurse line are still being sent to hospitals in AMR ambulances, rather than being diverted, program data reveals. And officials have exempted those nurse-ordered rides, like Hogan’s, from city standards that normally require the company’s ambulances to arrive on time.

It’s possible that Hogan’s experience was an aberration. But the city stopped tracking ambulance waits like hers in 2022, so officials have no way to know. [...]

***

Hogan’s wait started when she dialed 911 on the afternoon of April 8, 2022.

“I’ve got really bad knees because of rheumatoid arthritis and there is damage to them as well, and I’ve gotten to the point where I can’t get up,” she told the Fire Department dispatcher who answered, according to a recording of the call obtained through a public records request. “I’d like to go to the ER and have them look at my knees.”

Hogan had used 911 for emergencies before, assuming this time would be the same. Instead, her call was transferred to the nurse line operated by AMR’s parent company, Global Medical Response, from a call center outside Dallas.

“I’m going to bring the nurse on the line here and let them kind of help figure out the best course of action,” the Fire Department dispatcher said.

Hogan told the nurse she had been stuck in bed all day and had completely filled an adult diaper, according to a recording disclosed by AMR in the Hogan litigation. She described her pain intensity as 10 out of 10.

“I will get someone out to you,” the nurse said. “To get you to the hospital.”

Then the nurse ordered an ambulance, recommending care within four hours, according to another recording disclosed in the Hogan litigation. An AMR dispatcher in Seattle said it would take three to four.

Neither of them told Hogan, who was no longer on the phone.

Strained system

In the years before Hogan’s emergency, the Seattle Fire Department and AMR were dealing with a mounting number of 911 calls from patients with low-level needs, said Michael Sayre, the Fire Department’s medical director.

A sore throat. Anxiety. A stomachache. Patients who don’t really require emergency transport and care. The city received 44% more low-level medical calls in 2021 than in 2017, according to Fire Department records.

Few 911 patients receive lifesaving interventions and most emergency room visits are for nonemergency issues, national research has shown. People sometimes dial 911 not because they’re in imminent danger but because they’re not sure whether they’re sick or not, Sayre said.

These patients put pressure on the Fire Department’s dispatchers, who work long, grueling shifts. Such calls often involve homeless people or other patients without regular doctors, noted Ensign, whose decades of Seattle-based work has focused on health and social inequities.

“They don’t know what else to do, so they call 911,” Sayre said.

For acute 911 calls, the Fire Department sends its own highly trained crews. They can transport patients in red Medic One ambulances or hand the patients off to AMR emergency medical technicians in white ambulances.

For less-acute calls, the department may simply send AMR. One way or another, the company handles most of Seattle’s ambulance responses, approximately 50,000 annually. [...]

New program

Like other cities that use ambulance contractors for 911 callers, Seattle allows AMR to bill patients. In return, the company must meet standards for patient care: For years, its ambulances were supposed to arrive within 11½ minutes for more-urgent calls and one hour for less-urgent calls, at least 90% of the time.

But in the wake of the COVID pandemic, AMR was struggling with ambulance staffing in Seattle, arriving late for many of its 911 patients and paying a price, Fire Department records show. The city assessed the company almost $1.4 million in contract penalties for ambulance delays in 2021.

Enter the Nurse Navigation program, which Seattle and AMR leaders said would relieve that strain and improve ambulance response times in the city by diverting low-level callers to cheaper, better solutions. When it launched with fanfare in February 2022, then-Mayor Bruce Harrell called it “a strong example” of how to make a system “more efficient and ensure better care at the same time.”

The idea wasn’t new: King County had been using a 911 nurse line on a smaller scale for years, and cities across the world were experimenting. When implemented well, these programs can deliver real benefits, many experts say.

Seattle preferred not to hire its own nurses, said Sayre, the medical director, citing the costs involved. So the Fire Department turned to AMR, which agreed to triage the city’s callers almost for free. AMR had launched Nurse Navigation in Washington, D.C., in 2018 and had been attracting positive attention. [...]

Requirements removed

Before Nurse Navigation, patients like Hogan could expect assistance in under an hour. That changed in 2022 with an amendment to AMR’s contract that gave nurse-ordered ambulances a reprieve from any response-time standards.

Seattle and AMR officials say this made sense, because the nurse line is allowing ambulances to prioritize critical patients over stable ones. The company is no longer incurring late penalties for its Seattle responses still subject to time standards, a representative said, citing the nurse line and better recruiting.

But the city removed a significant guardrail when it removed standards for an entire category of ambulance rides, experts contend. Last year, more than 4,600 rides ordered were completely exempt from time standards and contractual penalties.

“Your community’s leaders may think 10-hour waits are OK,” said Matt Zavadsky, a nationally recognized health care administrator who managed a 911 system and helped start a nurse line in Fort Worth. “If your community’s leaders are not OK with that, you need a contract that prevents that.”

Instead, Seattle has left itself in the dark. Response times for nurse-ordered ambulances are excluded from AMR’s monthly reports to the Fire Department, so the city doesn’t know how long patients like Hogan are waiting.

by Daniel Beekman, Seattle Times |  Read more:

Image: Jennifer Luxton / The Seattle Times

The Plastic Surgeon Summit

We’re in a plastic surgery “renaissance period.”

Dr. Yannis Alexandrides: It is busier than ever. There’s a remarkable year-on-year demand increase that we see in surgical procedures, especially for the face, but also for the body. This is a trend that we have seen through the pandemic, but it has accelerated the last year.

Dr. Akshay Sanan: I think plastic surgery is in a renaissance period right now because of people publicly talking about it. Plastic surgery is now part of your wellness armamentarium. People used to flex what gym they went to, that they had a trainer, and now plastic surgery is part of that flex. People love to rock that they had their eyes done or their face and neck done or their body done. It’s just part of the cultural shift that we’re seeing.

Dr. Jason Champagne: This is where social media comes into play, camera phones and Zoom meetings. You see yourself from all these different angles nowadays that maybe you didn’t notice in the past.

Dr. Emily Hu: I find it very generational: Those who grew up in the social media era with a lot of sharing and openness are also very open about telling their friends [about the work they’ve had done].

Sanan: There’s a shift in consumer or patient habits. More people in their late 30s, early 40s, they’re choosing surgery earlier to age gracefully instead of waiting until things are advanced. They’re like, “I’m not going to wait until it drops down further. I just want to be hot in my 40s.”

Dr. John Diaz: It used to be that not everyone had access to a plastic surgeon. That was reserved within the realm of the elite. Well, not anymore. I have celebrities, executives, and business owners come in — but also teachers and waiters. There’s this democratization of attractiveness.

Dr. Paul Afrooz: Patients are very educated these days. They know what they’re looking for, they know what realistic results are, and they have the ability to do a lot of background research and understand who does things at an elite level. [...]

Let’s get into it: Why are we talking so much about facelifts this year?

Diaz: Facelifts have absolutely exploded for a few reasons. A lot of women see celebrities and influencers suddenly looking incredible, and they want to know how. Think about Kris Jenner — she had a huge impact when her pictures came out. And now it’s brought awareness to the fact that we have the technology to be able to take a young-looking woman and make her look better with surgery, without making her look fake. That was a real challenge 20 years ago.

Alexandrides: Kris Jenner was a very hot topic the last few months. Definitely a lot of the patients I see here take her as, let’s say, a model on how they want to look, because she looks fresh, but she doesn’t look pulled. She looks younger, and she looks happy, and you cannot see the scars, at least not in these pictures that we see.

Hu: I can’t tell you how many of my patients are like, “Yeah, my mom had a facelift. She was so scary. I’m never doing a facelift.” I mean, that was their response because they see their mom all bruised and scary looking.

Dr. Mark Murphy: Facelifts historically had a stereotypical “plastic surgery” look. Now people have realized, “I can look like myself 15 years ago and not have to look like a circus freak for it.” It’s become very digestible for patients. Social media is a huge driver behind it. Well, that, and the techniques are better.

So what’s actually new or changing about facelifts?

Dr. Mark Mani: We call it the golden age of facelift surgery. It’s primarily because of the success of the deep plane facelift.

Dr. David Shafer: There’s nothing new about [the deep plane facelift] as a procedure. It’s just very sophisticated marketing that’s being done now, and there are refinements to the procedures. But it’s not some plastic surgeon who’s marketing it now as some magic procedure that he came up with that nobody else does.

Mani: [A version of] the first deep plane lifts was performed in the late 1960s by a surgeon named Tord Skoog in Sweden [though the name came later]. I have his textbook and can show you results that would stand up to the best deep plane surgeons today. It’s not the procedure, it’s the surgeon, and facelift surgery, among all surgeries in plastic surgery, is an art form.

Afrooz: A surgeon named Sam Hamra — he just passed, but a wonderful human being, an extraordinary thinker, an extraordinary surgeon — first coined the phrase “deep plane facelift” in a 1990 paper and laid out some building blocks of the procedure. Just like everything else in plastic surgery, we stand on the giants before us.

Dr. Michael Stein: There are two main facelift techniques: deep plane and SMAS plication. The deep plane facelift is where you cut the layer under the skin called the SMAS, dissect underneath it, and tighten it in addition to the skin. In the SMAS facelift, instead of cutting and elevating the SMAS, you suture it to itself to tighten it from over top.

Dr. Amir Karam: The majority of surgeons, up until recently, have been doing the traditional SMAS technique, which is more or less horizontally pulling the face sideways, and that was leading to a very unnatural look.

Mani: I was the surgeon who wrote the most-read facelift academic article that convinced other surgeons to do deep plane facelifts. It was an article in Aesthetic Surgery Journal in 2016, where I detailed the specific anatomic reasons that deep plane is better.

Stein: The people who only do deep plane facelifts say they have a more longitudinal result, and vice versa. But the truth is, a good result is a good result. It depends more on the surgeon versus technique. A good facelift is a good facelift.

Facelifts aren’t done evolving.

Karam: The consumer is driving surgeons to create better and better results. So there’s been a massive increase in interest for surgeons to level up their strategies surgically and learn new techniques that are not new but new to them.

Afrooz: Even my facelift today is better than my facelift was one year ago. When you hone in on one thing as your career, you’re just constantly looking for ways to improve. It’s the cumulative effect of small subtleties over time and practice that you notice nuanced improvements to your results. One might assume that a deep plane facelift in one surgeon’s hands is the same as it is in another’s, but I’m here to tell you that it’s very much not the same.

Dr. Daniel Gould: There are new layers that we’re adding into the surgery. We’re recognizing the importance of the mid-face and volume position there. I’m recognizing adding fat to the mouth and the areas around the mouth, the chin, because all these areas have been neglected. We are now nailing all the low-hanging fruit: We’re nailing the neck, we’re nailing the face, we’re nailing the temple and the brows. Now it’s time to move forward and continue to innovate and push the limits of what we can really do in facial rejuvenation.

Mani: What I’ve developed is called the scarless lift, and it’s basically a deep plane facelift without a scar in front of the ear, with an endoscope. The endoscopic procedure involves a hidden incision within the hair, a short one behind the ear, and sometimes one under the chin. I still do about 60% open [non-endoscopic], but a good percentage of my facelifts are scarless endoscopic. The results are more beautiful because you don’t have to worry about the scar, and the vectors of lifting are better.

Alexandrides: I don’t think this will be now, “OK, let’s forget about facelifts, let’s move to something else.” What will probably happen is that people will discover intricate little different techniques and say, “You have the facelift that is done like that.” I have patients who ask me very technical questions: How do you design your scar around your ear?

Stein: Facelift surgery has survived the test of time. Every year there are new machines designed to tighten skin, and for some patients with mild laxity, they may see nice results. The truth is though, if you have jowls or droopy skin of the face and neck, the only thing that’s really going to give you the best bang for your buck and directly address your laxity is a facelift.

by Bustle Editors, Bustle |  Read more:

Image: uncredited