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Friday, June 24, 2011

Paradise Lost and Found and Lost Again: the Mission of Playgrounds

As a parent of a young boy, I spend a lot of time on playgrounds. I like the rock climbing walls and appreciate a good fast slide. I also really like swings that have really long chains since you feel like you are flying.

My young boy likes the animals or cars that rock on large springs, a large sand box, and the dome jungle gyms. There are a lot of other features which are hit and miss. In general, if my little one can play on most of the equipment without getting frustrated, we're happy. It's a bonus, if I can spend some times swinging on monkey bars and refraining from looking too triumphant if I successfully swing across.

I thought that the societal role and social mission of playgrounds was fairly straight forward and transactional relationship. Until I went to New York City where I learned about the Rockwell Foundation and other architect's mission to transform society and create a future paradise through playgrounds.

Some of the quotes from the linked article (which require a subscription to see the full text) include the 1959 United Nations declaration about playgrounds as "as a place where children, by playing, learn to become non-playing adults." Alternative perspectives include playground development as a substitute for war training. On the other hand, playgrounds that introduce too many repetitive tasks like the 3 S's of swings, slides, and see saws are considered to tools of oppressors to stifle creativity in children.

Architects like Rockwell, Gehry, and others that we have never heard fought these pedestrian playground design and developed "Playgrounds in a Box" and "Loose parts." Children were entrusted with more control over pieces of the playgrounds to encourage the discovery and creativity process. Whacking each other with foam noodles is one example of this process.

Overally, their goals were best summed up with the following quote from the article:
Over the past century, the thinking about playgrounds has evolved from figuring out how play can instill youngsters with discipline to figuring out how play can build brains by fostering creativity and independent thinking. The hope of Rockwell's playground project is that children who have experimented with fitting together oversized blocks and cogs-and who have learned to navigate a place where the social challenges of sharing and collaboration are built into the experience-will be better equipped to handle the complexities of twenty-first-century life.

How did our experience with playgrounds changes through these carefully designed New York City playgrounds. Were my youngster and I transformed in anyway? I am going to answer in repetitive bullet points so you can clearly see that I am a lost cause for these playground architects:

  • We watched slightly older kids take over water sources or fountains and spray other kids who got too close. As the designers intended, kids learn at an early age that sharing is for the weak and they should dominate key resources.

  • A group of kids were digging an elaborate canal system in the sand. Two of them yelled at all the other kids to dig more and dig faster. It was inspiring to see their imagination settling on building their own sweat shops.

  • One two year old was very vigilant about tearing down any block or "Loose Parts" construction that any child built and left alone for more than 15 seconds. Clad in baggy back shorts, a medallion around his neck, and a pot belly, he looked like a little mob enforcer. Actually, he might have been.
It looks like the playgrounds do mimic the work environment quite well. This is New York City.

Wednesday, June 8, 2011

Be the Change that you can Abdicate to Others

Not quite the snappiest title like "Be the change that you see in the world" which is both a popular bumper sticker and looks good on the back of graduation T-shirts from social work programs. However, I like the word "abdicate" as much as I like the word "colonoscopy" and it's easier to spell.

The fact that I completely digressed before I even started writing the post is completely impressive, too. I can't even use "But I digress" as a transition. My point is that local governments are running away from making any difficult decisions in designing health care systems. Their lack of boldness is making Wisconsin governor Scott Walker's decision to declare war on organized labor look good because at least he made a decision and stuck to it.

The state of Oregon has provided some very fine recent examples of such abdication with their Medicaid program. Rather than make difficult, thoughtful decisions to guide the program, they throw half baked ideas to health plans and providers. They are:

1. Charge copays for services. The state gave the option to charge a $1 to $3 copay to non-Native American adults for prescription drugs and primary care. This was intended to reduce the amount of money that the state paid for services by passing on the costs to the Medicaid beneficiaries. However, trips to the emergency room were still no cost to the Medicaid beneficiary. In an effort to save money, the state made an incredibly poor benefit design decision and and as a bonus, set up in a way that was difficult to administer. Providers would have to figure out who they could collect $1 to $3 from and what to do if that individual did not have any money (like send them to the Emergency Room rather than give them their $4 generic prescription drugs).

Almost all the carriers decided not to implement this copay scheme and just take less money from the state. This is an example of a bad idea to save money that the state floated to health plans and providers. It went over like a lead zeppelin. This was an opportunity to have a serious discuss about benefit designs and what Medicaid beneficiaries should pay for and what they should not pay for. Incentives could have been developed to guide positive behavior and punish negative behavior. Instead, an administratively unwieldy option was offered to punish positive behavior. The end result was a waste of time.

2. Ask health plans what the reduction in Medicaid costs should be: Oregon is facing a budget shortfall and has stated that it plans to reduce Medicaid spending by 19%. Another option is increase the provider tax in order to get more federal matching funds and face a 10% to 12% reduction. Oregon also has a rule that its Medicaid spending must be actuarial sound. That means if they want to cut costs by 10%, or 12%, or 19%, then the health care services used should also be projected to reduced by that same amount. This also provides yet another example of how actuaries are guaranteed employment forever.

Oregon has proposed some good ideas to redesign their Medicaid system to achieve those savings. However, they don't think that they can achieve the savings this year. They are squandering a perfectly good crisis and asking health plans to come up with their own actuarial sound analysis of the lowest cost to provide health care services for Medicaid beneficiaries. In other words, they are asking health plans what the cut in spending should be. This is a crucial decision in Oregon's Medicaid program and they asking health plans to do their homework for them.

A budget cut is just a loss of services but a budget cut and a health care system redesign is an opportunity. Under health reform, states have more options available to transform their health care system with Xxchanges that will allow them more control over the health insurance market. There are "pay or play" options where carriers must participate in Medicaid or providing guaranteed issue to children or face a financial penalty. This is the opportunity for bold and difficult decisions for states to make that will change the lives of their most vulnerable citizens.

This is not the time to buy a vowel.

Saturday, June 4, 2011

Death's Door Bandit; A Sad Tale about the US Health Care System

An elderly gentleman walked into a bank and indicated to the teller that he had a weapon. The teller was convinced enough about the danger or nauseated enough by his ear hair that they considered the threat to be serious. Before anyone handed him the money, the gentleman collapsed into a chair and had a heart attack.

This turned out to be an actual lucky turn of events for our ear haired protagonist because he had robbed the bank to get money to pay for health care. Due to a 1976 US Supreme Court decision, it is considered cruel and unusual punishment for a prison not to provide health care. Since the elderly gentleman was now in the prison system, he got the medical care that he needed.

However, there is a plot twist for the Death's Door bandit (This is a better term than the Ear Haired Bandit. I don't know if he had ear hair or not but if he is over 65, it's safe to assume that he did. The Bleeding Heart bandit is also an option). Readers may be wondering if the Death's Door bandit (DDB) was old enough to qualify for Medicare, the health insurance scheme for senior citizens. Not only was he eligible for Medicare but also Medicaid, the health insurance scheme for the low income! In case anyone is wondering, why I am calling Medicare and Medicaid a scheme, it is because I am imitating the Economist who uses that terminology. If you read it with a British accent, it sounds much more regal.

DDB is getting his health care paid for by the prison system but could also get his health care paid for by Medicare and Medicaid. He will no longer need to rob banks for health care so this story appears to have a happy ending. But wait, this scheme has a plot twist!

Heart attacks and medical care for senior citizens whose physical and mental status has decompensated to the point that they don't even realize that they qualify for basic government programs is not cheap. It's costly enough that administrators for the prison health system and Medicare and Medicaid started to pay attention. Both administrators took the high road and began to maneuver to try and stick the other one with DDB's medical bill. Medicare and Medicaid administrators want DDB to stay in jail so the prison will pay for his health care while the prison administrators wants to release DDB so Medicare and Medicaid will pay for his health care. The justice system is caught in the middle.

Only in America. Our health system must rank number one in something for this scenario.

Full disclosure: This is a true story. Names and details would have been changed to protect the innocent, except there are no innocent in this story.
Full disclaimer: I don't know the difference between disclosure or disclaimer.
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