Stephen Dubner admits that he and the team behind Freakonomics Radio sometimes explore ideas most sane people would leave untouched. This time, Dubner decided to look at the economics of end-of-life health care.
It’s certainly a touchy subject, but also one that most families will have to face at some time in their lives.
Dubner poses the question: “What if someone was suffering from a terminal illness and they had the option of forgoing standard-end-of-life medical care, and instead they could get a cash medical rebate from their insurance companies?”
He’s calling the idea the Glorious Sunset Proposal, and the Freakonomics folks even made a fake commercial so you can hear how it might be pitched.
Dubner took the Glorious Sunsets Proposal and shopped it around to health care experts to see what they thought.
Health care economist Uwe Reinhardt wasn’t having it. Reinhardt says if he were an insurance company CEO, he wouldn’t offer a Glorious Sunsets option. As a health insurer, “your incentive is actually, in many ways, to increase health spending,” Reinhardt said.
When Dubner took the idea to doctor and bioethicist Zeke Emanuel, he wasn’t interested either.
“It’s so cold blooded, it’s so calculating, it’s so utilitarian that it’s not American,” Emanuel told Dubner.
Thomas Smith is an oncologist at Johns Hopkins. Dubner says Smith actually tried a Glorious Sunsets-like experiment years ago that gave cancer patients the option to forgo treatment and keep the money. But the experiment failed.
“Our patients were actually interested, but their doctor/providers weren’t,” Smith said. “It’s pretty hard to look at those two choices and decide what to do.”
It’s clear these three health care experts weren’t thrilled about the Glorious Sunsets Proposal. But Dubner says all three people — and more — that they spoke with did agree on one thing: “If anything in our health care system really needs to be revolutionized right now, it’s end-of-life treatment.”
But Dubner says, in the end, the economics are perhaps the least important factor. He points to what Zeke Emanuel had to say on the matter. “The health care system, instead of talking to a patient and getting it right, we sort of pound on their chest and try to resuscitate them, even when that may not be what they want,” Emanuel said. “And I think trying to get what patients want ought to be our primary focus."
Dubner says doctors may soon pay more attention to what patients want. “The Centers for Medicare & Medicaid Services has just proposed a regulation that would actually finally pay doctors to do nothing more than have a conversation with patients about their impending death,” Dubner says.
Maybe it’s not Glorious Sunsets, but it’s “certainly a step in the right direction,” Dubner says.
Click on the audio player above to hear the fake ad and the full interview.
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The coal industry is struggling as cheaper and cleaner natural gas undercuts coal, and environmental regulations push utilities to shut down their older coal-burning plants.
Yet new coal mines open and others expand. In one Texas county on the Mexican border, local officials and residents seem nearly united in their opposition to a new coal strip mine, the Eagle Pass Mine. The company that owns it, Dos Republicas Coal Partnership, says it intends to ship out the first load of coal by train next month.
The Dos Republicas Coal Partnership owns the Eagle Pass Mine.Ingrid Lobet
Dos Republicas is backed, through layered ownership, by a major Mexican steel and coal firm, Altos Hornos de Mexico, S.A. All the coal from the Eagle Pass Mine is bound for Mexico. It will fire the Carbon I and II power plants half an hour south of the border in Nava, in the state of Coahuila.
“The excuse is that ‘we need energy,’” says Martha Bowles Baxter, a resident of Eagle Pass who opposes the mining plans. “Well, the energy is going to Mexico.”
It appears to be the first time a coal mine has been opened in the United States to serve a power plant in Latin America.
George Baxter, her husband and a civil engineer, says the smoke from the generating station in Mexico often drifts north to Eagle Pass.
“You see the brown line, horizontal line of pollution," he says. "It extends as far as the eye can see.”
Now, he says, those results of burning coal will be added to the insults of mining it.
“Apparently the war on coal does not extend to Maverick County,” he says.
The Baxters’ chief preoccupations are widely shared. The local school district, city council and hospital officials oppose the mine. Many concerns focus on water. The Eagle Pass Mine intends to discharge into Elm Creek, which runs through the mine just before it joins the Rio Grande. Less than a mile downstream, the city of Eagle Pass takes its drinking water.
Elm Creek neighborhood residents fear that floods, like this one in 2013, will carry mine silt and waste from the Eagle Pass mine on either side of the creek. (Permission to reprint granted by Eagle Pass Business Journal)
Events in recent months have heightened a second water concern. The Eagle Pass area has had two 100-year floods in two years, according to David Saucedo, the Maverick County flood plain administrator.
“In 2013, we had 16 inches of rain in a 24-hour period," he says. "In 2014, we had 12 inches in a 24-hour period.”
One hundred and twenty houses were damaged or destroyed.
“You have seen these people go through these things," says Saucedo, who is also the Maverick County judge. "And on top of those floods, now you have to worry what is in the water? It weighs on you.”
The chance of two 100-year floods occurring back to back is one in 10,000. Texas mining regulations require that the ponds that collect heavy rains before they carry silt into the creek be dug deep enough to withstand just a 10-year flood.
Flood maps from the Federal Emergency Management Agency indicate an official flood zone along the creek where it runs through the mine, so Saucedo opposed the mine’s flood permit. The company sued him. A lower court judge agreed he acted within his authority and that case is at the state’s 13th Court of Appeals in Corpus Christi.
In the course of those arguments, the mine has gone from paper to reality. Sixty million dollars worth of equipment has arrived at the site, hundreds of acres have been excavated and offices and parking lots for workers carved into the mesquite.
Yet Martha Bowles Baxter believes another flood, this time carrying mud or mine waste, is inevitable, and that many homes will be in the path of the water. The local newspaper refers to the area directly adjoining the mine as “densely populated.”
“When FEMA comes in, they are going to render all of that land completely contaminated," she says. "And those people are going to be losing all their homesteads, what they plan to give their children. And no one cares because this area is very, very poor and Hispanic."
Some residents of Eagle Pass, Texas, note that residents living near mines on the Mexican side of the border complain of soot and land settling, which causes cracks in dwellings. This banner, from Palaú, Coahuila, Mexico, accuses mine owners of assuring their own future at the expense of local children. Alonso Ancira (his last name is misspelled above) is a principal investor in the Mexican and the new Texas mines. Rudy Rodriguez, who represents the mine owners, says not all of the mine area is in the flood plain, and engineered ponds at the mine will actually ameliorate flooding. The mine plan also complies with numerous agencies’ requirements and all state and federal law, he says.
Already, Rodriguez says, hard-hit Maverick County is benefiting from the tens of millions of dollars the mine has spent on equipment. At the mine, he points to a mechanic changing a tire on a truck so large it makes his Cadillac Escalade look like a Matchbox car. The tire alone cost $35,000, he says. Under the current footprint of the mine, which the owners seek to expand, it would inject more than $147 million into the local and regional economy.
By one measure, the project has been popular: It held a fair to connect with local vendors and would-be employees.
“We started at eight o’clock in the morning and went on in the evening,” Rodriguez says. “We had so many people want jobs — 680 applicants for 100 jobs.”
Saucedo says most of the town would rather see retail employment. Eight thousand people signed a petition against the coal mine, he says.
“To put that in perspective, you had 5,500 people come out to vote in the last election," he says. "Now, when you have more people signing a petition than going out to vote, that should send a message.”
On Aug. 10, the U.S. Army Corps of Engineers held a hearing in Eagle Pass to gather public comment, following a request by Dos Republicas to add 25,000 acres of potential mine area to its existing 6,346 acres. According to the Eagle Pass Business Journal, all 28 people who testified, including Eagle Pass Mayor Ramsey English Cantú, spoke against the mine and its expansion.
With the economy still recovering, and the chaos with the stock markets and China, business is tough in the U.S. Lisa Goldenberg, president of the Delaware Steel Company, says things “could always be better. We’re still in recovery period…. Recovery, good recovery, takes a long time, years, 10 years.”
In addition to that, Goldenberg has to keep her eye on the ups and downs happening in China.
“China is the largest steel producing market in the world, so you know I’m watching it every day,” she says. However, she says that the most recent upset with the yuan devaluation hasn’t directly hurt business.
What has hurt her business is the strong U.S. dollar. Goldenberg explains: “For my daily business, I’m a proponent of a much weaker dollar…. For my business, it rocks my world.” When the dollar is strong she has a tough time exporting anything. “I have zero business, not a little, zero when the dollar is strong.”
The strong dollar isn’t the only thing affecting business. There’s also the cost of shipping and freight.
“In the United States, there are so many other factors to shipping across this country than the cost of fuel," Goldenberg says. "We want our drivers to be insured, we want the roads to be safe, we want drivers to be certified and have proper resting times, and have weigh stations, and all the things we’re used to in a developed, sophisticated economy. And those things are very, very expensive.”
It’s hard to conduct business in this hectic economy when everyone is just trying to stay afloat. “It’s very, very stressful. It wears you down. And keeping your employees motivated, keeping their families safe and secure and confident is a full-time job. This economy is not for the faint of heart,” she says.
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