Wednesday, April 27, 2016

Israel & Foreign Aid

Let me begin by saying that I believe in foreign aid.  I think properly used, foreign aid can be a significant tool in our national security in addition to making the world a generally better place. 

We give a significant amount to Israel each year - $3 Billion.  It is the largest recipient of US government aid.  That equals a little more than 1% of their entire GDP and almost 4% of the government budget.  It essentially goes there with no strings attached.  A group of legislators have proposed that we raise that amount to about $3.7 Billion and Israel is hoping to see it raised to between $4 & $4.5 Billion.

To put those numbers in context.  The population of Israel is roughly the same as either New Jersey or Virginia.  New Jersey is the state with the lowest return on its federal tax dollars in the US and actually ends up with roughly a negative $23 Million each year.  That is, NJ sends $23 million more to the federal government than comes back to the state.  Virgnia is the state with the highest amount of return from the federal government.  It receives about $97 million more than it sends in in federal taxes.  Look at those numbers for a second and realize that the state with the highest return on its federal tax dollars gets back less than 1/3 of what we sent to Israel this year... and there are obviously strings on much or most of that money.  Israel, on the other hand, continues to break international law with the building of settlements.  Additionally, 1 of 3 Israeli families receive some kind of government welfare including large numbers of ultra-orthodox Jews who live on state subsidies for religious study.  Some studies show that 65% of ultra-orthodox men do not work but instead spend their time being paid by the government to study torah and scripture. The ultra-orthodox are also the fastest growing Jewish segment of the Israeli population.

Some economists are arguing that the Israeli economy will collapse under the weight of its welfare system.  It is no wonder that they are hoping for a significant increase in our aid... On top of those who are paid to not work, Israeli citizens receive other benefits that US citizens do not.  All universities are subsidized by the state and students pay only a small percentage of the actual costs.  Health insurance is universal and looks to me roughly like Medicare for All.  One could easily argue that we subsidize all of these benefits.

So what do I think we should do?  I think that aid should be tied to real actions that reflect our values.  Should we dictate to Israel how they should live?  No.  But neither should we subsidize their choices when they conflict with our own.   Here are two examples.  We refuse welfare to criminals in the US... tie our aid to the dismantling of settlements and to better treatment of the Palestinians.  We hold as one of our deepest values separation of church and state... tie some aid to the removal of special perks for ultra-orthodox sects.

Friday, April 08, 2016

An Imagined Reality



Folk who know me know that I'm feelin' the Bern.  I've had some good conversations with friends who definitely don't feel the same and some have raised interesting critiques of Bernie Sanders.  One friend said that Bernie should not be president because he simply doesn't understand how the world works.  I disagreed and responded that perhaps it is not that he doesn't understand how the world works but instead he is offering a different paradigm as to how it should or could work.

Recently I read a really fascinating book called Sapiens: A Brief History of Humankind.  Of all of the ideas in the book, the one that really caught my imagination is that everything works because of our unique ability to imagine a paradigm and then agree upon it.  Those imagined realities enable large groups of humans to work together, to trade with one another, to form societies.  Basically the author, Yuval Noah Harari, says that there is nothing in human society that does not depend upon those imagined realities upon which we have agreed to agree.  And those imagined realities can be changed.

I was thinking about one of those imagined realities the other day when an editorial in our local paper complained that the problems with the dollar began when its value was cut off from anything real - i.e. gold.  But, the value of gold is also tied to nothing "real."  The book uses gold as an illustration of imagined realities.  While the metal does have some iteresting properties, there is no reason beyond a cultural agreement that it should hold any more value than some other metal, many of which are significantly more useful.  Ineed, when the Spaniards arrived in the new world, searching for gold,  the native people were confused.  Gold is pretty, they thought, but too soft for any important uses.  They imagined much lower value for that soft yellow metal.

Back to Bernie... there is no reason beyond the fact that we have all imagined the world as it is that it should remain that way.  We have decided that some people should be incredibly wealthy while others struggle and even die from want.  We have decided that a freakishly tall, athletic man should make tons of money for entertaining us with incredible feats that we cannot accomplish while the one who picks our food, bent over in the hot sun in a field day after day, struggles.  Why?  The list could go on.

Now Bernie is not calling for crazy changes.  Indeed, many of the changes he envisioned are already part of the imagined reality in much of the world but it is a different reality than the one we've adopted together in the US at this point.  That is why he is revolutionary.  That is why he challenges the powers that be.  That is why I'm feelin' the Bern.  I want to see a new paradigm and the one he is offering is a lot more like the one I believe that God imagines for us than the one we currently have.

Tuesday, April 05, 2016

Medicare

My spouse becomes eligible for Medicare this year so we've been paying attention.  We've had to pay attention to insurance for a number of years as I have a genetic condition that causes a chronic disease.  It has been under control for me since 1987 but that is irrelevant.  On the open market, I was not insurable at any price.  I had medical insurance available through our denomination but it was nearly $4K a month and was no longer affordable by my employer or my family.  The ACA saved us... me... literally. (This is not about the ACA and I see serious problems there which I have addressed before a number of times).  So paying attention to Medicare didn't feel unusual.

I noticed quickly that while some folk have complaints, few of them are the elderly folk on Medicare... and the complaints that population does have are no different than the general population dealing with any insurance company - costs, restricted access, complexity...  I do hear younger folk who say that Medicare is proof that the government can't run a healthcare insurance system.  They say it is nearly bankrupt and doesn't work anyway.

So, with those thoughts in mind, we went to a two hour seminar yesterday to get a basic understanding of Medicare presented by a non-profit that advocates for the elderly and helps them with issues around Medicare.  I came away with some impressions... Medicare is too complicated.  Negotiating part D and supplemental plans is difficult and clearly a lot to ask of some seniors.  $300-400 a month for a newly retired person in California for part B, a reasonable part D, and an F class supplemental plan is a lot of money, especially for someone on a fixed income... and it will only go up.  The "free market" alternative - Medicare Advantage - may work somewhere, but it requires a population density that we don't have where we live so the choices here are thinning rapidly (there are only three plans available in Santa Barbara county now and only one that covers the entire county) as the companies can't make the level of profits they desire.  Even where it might work, it still has the significant limitations commonly associated with HMO's.  The donut hole is scary for someone with a chronic condition but the way that the ACA is filling in the hole is at least a little heartening.

It seems that making Medicare a single payer system, eliminating the need for Part D and supplemental plans would go a long way to simplifying the system.  Both pieces feel to me like compromises made with the private sector so they can continue to get some portion of income from this group of high consumers of medical care.  We are worried about the realities of paying that much money a month for insurance after having employer provided insurance our entire lives but I am more than glad to know that I will at least have coverage.  I anticipate that at least one of my meds (which is stupidly expensive) may not be covered but that will be what it is.  I have 3+ more years until I become eligible and another year beyond that until retirement so some of those worries are meaningless.  A Republican president and congress could make the entire program go away.  A Democratic one of each might strengthen the programs... time will tell there.

Of course there are the big public policy questions that continue... Is healthcare a right that everyone should be provided regardless of their economic condition? For me as a theologian, what are the theological implications of that question?  How do we control costs while at the same time insuring good care?  And for me a central question, what role should the profit motive have in healthcare?  (I would argue none)

Wednesday, March 30, 2016

End of Life Choices

Last October, after my state passed a law allowing physician assisted suicide, I posted a blog about the issue.  I struggled and continue to struggle with the question.  Here's a paragraph from that post.

I saw images on 9/11 that made me think differently.

We also saw people jump from the towers to their deaths, knowing that they were committing suicide.  At the same time, death was imminent as the flames came towards them.  The choice was clearly between dying a painful death of burning or a quick one from the impact of a fall from the towers.  I don't know what I would have done if faced with that choice but I do know how I feel about burning and it is not a way that I would choose to die.  So, I asked myself, was the decision to jump an immoral one?  Did I have the right to condemn those who would choose one way to die over another, knowing that death was clearly coming?
 My thinking was prodded forward by the situation of Brittany Maynard, who suffered with a terrible form of brain cancer and chose to move to Oregon so that she could take her own life rather than go through the process of the cancer.  I watched a friend die of that same cancer so I knew a bit of what she was facing...

The other side of my equation is that my spouse is a hospice chaplain.  During Cheryl's years of work in that challenging setting, I have learned that those final days can truly be holy time and that in spite of (perhaps sometimes because of) the pain, relationships are healed, grace is poured out, and that life is enriched in ways that could not be imagined under normal circumstances.  In his book, The Four Things that Matter Most, Ira Byock tells story after story of families who look back at the last days with a loved one as some of the most positive time they shared together.   I also know that sometimes even the most dire prognosis can be wrong and that individuals who really should die, simply don't.  Cheryl has had more than one client who was supposed to have a prognosis of 6 months or less but instead lived for years.

All of that is to say that I fear by making it easy to avoid the difficult times, we will also see many families missing out on the wonderful times that are enabled by the nearness of death.  I also fear insurance companies pushing "a good death" because it costs much less than the protracted experience of dying well.

I really do understand the reason why some folk may want to end their own lives as a way of avoiding terrible suffering and I do think the law is probably a good thing.  Still, I hope that we find a way to open other options that truly can be filled with grace.

Tuesday, March 08, 2016

Free College?

Why do we have public education?  Seriously.  Why?  And why provide it essentially from age 5-18?  Again, it is a serious question.  Obviously, it is not free.  We provide teachers who incur salaries and benefits in buildings that are particularly expensive.  Then there are books and supplies.  All of which cost serious money (even if less than one might reasonably expect)... money that comes from the general public in the form of taxes.  We don't tax only those who are parents... why?  Why should I pay taxes to send someone else's children to school?  I'm finished raising children.  I paid for mine (and my own extended education).

I pay taxes to support education because I want to live in a society wherein the citizens are educated at least enough to be contributing members of society.  We provide education for our children because we require at least a minimally educated population or things get very ugly very fast.  So why through age 18?  I would argue that education has historically been provided in the amount required for an individual to be a productive member of society.  For a long time - during the agricultural age, 8th grade was enough.  That meant an individual could read and do enough math to be sure they weren't getting cheated when they sold a cow at market and that they could make reasonably informed decisions at the ballot box after making judgments regarding the claims of politicians.  We provided that for every child in every family and the broader society absorbed the costs.  An individual family that wanted to send their child further could do so on their own dime but the minimum was provided "free."  A child with an 8th grade education could become a fully functional and contributing member of society.  He or she could have a family, a home, and make a contribution.

When the industrial age took hold and life became more and more technical, 8th grade was no longer enough.  More complicated math was often required.  The world was becoming smaller so citizens needed to be able to reason a bit more to understand international issues.  One needed to read better to be able to understand manuals for complicated machinery.  As a society we added 4 years to what was provided "free."  It was clear that 8 grades was not enough but 12 seemed to meet the requirements.  A high school diploma was enough.  Again, a family that wanted to send their children to college or technical school could do so, but society both required and funded through high school.  An individual with a high school diploma could make a good living, raise a family, be a part of society...

A high school diploma is no longer enough.  The vast majority of jobs available to an individual with only a high school diploma could just as easily be done by a machine and it takes more training than just high school to run those machines.  We also live in a world that is becoming more and more complicated and ignorant populations do not make wise decisions.  Either college or technical education after high school is required for an individual to become a fully functional member of society.  If we as a nation do not provide those educational requirements, we run the risk of having a larger and larger underclass without any ability or hope of ever becoming a fully functioning member of the society.  That is a recipe for disaster.

So... Bernie Sander's call for "free" public education is not a pie in the sky dream.  It is a requirement for a healthy society.  "But it is so expensive.  Where will we get the money to pay for it?"  We get the money to pay for the things we think are important.  When the government decided we needed to go to war in Iraq & Afghanistan, almost nobody asked how we would pay for it.  When my county decided they needed a new county jail, questions of money came up but almost nobody seriously said, "let's leave the criminals on the streets."  So where do we get the money?  Raise taxes?  Perhaps.  Cut the military?  Perhaps.  Make it happen one way or another?  Absolutely.

Now how about the folk who incurred huge debts at exorbitant interest rates in order to become fully functioning members of society - taking on costs that the broader society took on in the past?  I would argue that at the very least, the government should take over the private loans and convert all student loans to 0% interest.  They aren't charging that much more than that to big banks that borrow money from the government... why not free a generation of young adults from that burden, allowing them to truly become fully functioning?

Thursday, March 03, 2016

Church Values

Two pieces came together this week to have me thinking about church values.  First, I listened to an interview with the pastor of a megachurch in the south who talked about the core values of his congregation.  While the wording might get under my skin a bit, I found myself more or less agreeing with the values he stated.  The part that hooked me was the clarity with which they were spoken.  The church has five very clear, short (the longest is 5 words) statements that give shape to their ministry.  The second piece is a blog post written by my daughter, "What are you doing?"  In it she raises the question of whether or not one's actions are furthering their primary path or taking them down rabbit holes. 

So I was thinking about the churches I've been a part of... I've been blessed to have been part of great churches doing significant ministry in their various settings.  While the values of those congregations have often been implied by their actions, none of them have been nearly so clear as to have 5 short clear statements which could be recited by anyone in the congregation or used as yardsticks to evaluate the direction of their ministries.  Of course, articulating values doesn't mean a specific church really holds them.  Nor does a list necessarily include all or even the most deeply held values of any given church.  For example, few churches would say they value the status quo above all else but many clearly do.  And while many churches might put evangelism as a core value - perhaps even their top one - few really live as if that is the case.  Still, at least trying to articulate them can only be a good thing.

So what are the values of Cambridge Drive Community Church where I currently serve? To what degree are they reflected in the shape of our ministries and our life together?  Are our resources allocated to support the things we value most or are institutional needs draining them more than the values would indicate?  We haven't clarified those issues as well as we could and should.  For example, I would say that one of our core values is that our buildings and land should serve the community.   In a typical month we have between 500 and 1000 individual people who use our property who are not directly affiliated with the church via concerts, recitals, 12 step programs, educational programs, and just enjoying the grounds.  Many of them are on the property multiple times in a month, some more often than even our most committed members.  While we charge for many of the uses, none are market rate and for many the church is essentially subsidizing the use.   We often wrestle with those costs and struggle with the difficulties of other folk using our "stuff."  If we had more clarity around those uses as a core value, the questions may be easier to address...

All of that gives me and us something to work on...

Saturday, February 20, 2016

Better Living through Chemistry

When I was younger, Dupont Chemicals used the tagline - "Better living through chemistry." I'm a case study that indeed, at least sometimes it is true.

I have an hereditary condition called heterozygous familial hyperlipidemia. Basically there are two genes that regulate the way the body deals with cholesterol.  In my disorder, one of those genes does not work correctly.  This results in extremely high cholesterol numbers - my total count when it was first diagnosed was 613 (normal is under 200).  There are some folk in whom neither gene works correctly - homozygous familial hyperlipidemia - whose total cholesterol counts are often above 1000. 

You are probably aware that elevated cholesterol is associated with coronary artery disease.  These crazy high numbers result in severe disease at earlier ages.  My biological farther died at age 31 from the artery disease associated with his hyperlipidemia.  An autopsy after his death revealed major blockages in every coronary artery.

Due to dysfunctional family issues, I was not aware of my problem until I had chest pains in my mid 30's.  By the time my disorder was discovered, there were a number of drugs available to treat my cholesterol problem - niacin in large quantities, bile acid sequestrants, and statins - the first of which was released to the market about 1 month before my diagnosis.  I began a regimen of all three classes of drugs.  My blockages were too numerous and too severe to do stents or bypass so even with the lower cholesterol, my prognosis was unclear.  Animal studies had shown that if the cholesterol could be brought to normal levels, the blockages may recede. The cardiologist told me that he didn't know whether the drugs would drop my cholesterol enough and that even if they did, the blockages may remain unchanged.  He advised me to get my affairs in order just in case. 

The drugs worked well and my cholesterol dropped more than anyone ever expected.  The side effects were/are manageable.  That hoped for result that hadn't really been observed in humans took place - my blockages began to recede.  Still, some of my numbers never really got to "normal."  My HDL's were still lower than they should be and my LDL's were still higher.  I had a friend who was diagnosed with the same disorder as me about the same time.  The drugs did not work for him and he died less than a year later.

Recently another new class of drugs have made their way to the market - PCSK9 inhibitors.  They are aimed at folk like me with genetic causes for their high cholesterol.  They are crazy expensive (about $14K per year).  My cardiologist started me on one (Repatha) about 3 months ago in addition to my current regimen.  The company - Amgen - is subsidizing some folk in using the drug and I fall into that category.  For the first time in my life, my HDL's are crazy low, my HDL's are normal, and my overall cholesterol is insanely low - 97!!!  If my blockages receded some before, they could recede even more now.

Assuming there are no terrible side effects, this bodes really well for me and for other folk like me... except... the price.  What about the folk who will be excluded because they cannot afford the drug?  I think of my friend for whom the earlier drugs did not work.  Perhaps these new drugs would have been the miracle that saved his life... if his insurance would cover them with a copay he could afford or if he fell into the proper category to be subsidized.  If not... 

Again we see the reality in our culture with regards to medical care.  Those with resources will live and those without... will die.