August 30th, 2008

the book in the mail was _Know Your Child_

So I tried to read the medicare politics books. This is sort of sad. It's a remarkably good book. But it is a slog. Also, I think it is perhaps not the best book to read at this point in the pregnancy, because at times I doze off. Oh well.

After T. went to sleep, I did some more reading on the VBAC Facts blog and it seems to be engaging in brownian motion with the policy theory in the medicare book. The author makes a number of points (sleep inducing, despite how interesting they are) about the interaction of the structure of policy and politics in the US and the changes (or rather conspicuous lack thereof) in Medicare over the decades since 1965. A big chunk of his thesis is that Congress is a policy making body in a way that is not the case in European states, and in a way that's deceptively hard for policy theorists to get a handle on. While Medicare is popular, it is poorly understood, so widespread political opinion and even interest groups in the public don't necessarily have a ton of influence year-to-year on Medicare policy, which means the "pros" wind up making a lot of relatively low-visibility decisions.

This is great analysis. Our rhetoric of "choice" by "informed" consumers/stakeholders/wtf is a fucking poor model for what happens with health care policy. I don't care whether you're talking about reproductive issues, screening tests, end of life care etc. Most people don't really know anything at all about these things. Even the people who are personally touched by these things (pregnant women, people going in for "annual" checkups, people trying to decide whether to buy long term care insurance and if so how much, people trying to find a nursing home for their aging relations, etc.) face a very NOT transparent industry and a steep learning curve.

I'm not arguing that justifies paternalism. Quite the contrary. What I am arguing is that we can certainly collect from stakeholders what their values are, assign a bunch of really smart people (ETA: including representatives of stakeholders) to spend all their time trying to find out everything they can about what the hell is going on in the industry, and then thrash out a compromise that does a decent job serving the respective groups. Which is to say, regulate the heck out of it. There are a wide variety of ways to do it (including NGOs, senate sub-committees, bureaucracies, etc.). We're trying some of them.

So when I see a post over on BlogHer justifiably complaining about a woman who was apparently denied health insurance because she had a c-section (particularly given the overly slice happy OB-GYN community in this country), followed up with comments about how maybe this will ultimately motivate women to fight harder to avoid c-section, I just want to smack someone -- and I'm not entirely certain who. Altho the MD who claims that homebirths don't reduce complications rates seems like a Real Good Candidate. I'm at this point old enough to strongly suspect that that MD (who, incidentally, is presenting as a woman) honestly believes the crap she is depositing -- just like ACOG's justification for their policy and attempts to legislate it in the face of resistance is probably not _consciously_ driven by a desire to have a stable and predictable schedule for their members with Christmas, Thanksgiving and regular weekends off.

I might be discouraged. After all, I can't tell whether the AMA's model legislation efforts against homebirths and cosleeping are an example of an ascendant power over-reaching itself and about to fall precipitously -- or an embattled interest group thrashing in its death throes (possibly prior to a phoenix-like rise from the ashes). I don't have any strong sense of whether things are about to get a whole lot better or a whole lot worse -- or go sideways in a conflicted and chaotic way, not unlike oil prices during this hurricane season. But I'm actually not discouraged. If the insurers and a lot of the customers are getting really peeved at the doctors, and there are legal action groups looking for people who got stuck with a section they didn't want looking to _sue hospitals and providers for banning VBACs_ (and there are -- I am not making this up), we could very well be looking at an effective counter to that particularly ill-judged ACOG policy against VBACs. _Especially_ since Healthy People 2010 is coming down hard on the pro-VBAC side, thus making the docs look like they've been completely isolated on this issue. If other countries did things the way we do, and midwives etc. didn't exist, this might not be enough. But our reproductive stats suck and other people do cheaper and better.

The OB gravy train has a few more years in it for sure, possibly even a decade or more. But I'm thinking ACOG must be feeling at least a _little_ embattled at this point.

_The Political Life of Medicare_, Jonathan Oberlander

Having finally finished it, I can only say good things about this academic analysis of the history of Medicare, politics and policy, from before it was signed into law in 1965 through to 2002.

Oberlander brings several lenses to bear on the problem. He describes how it was _not_ created as part of the New Deal, even tho it was desired at the time it was sacrificed due to resistance on the part of the AMA among others. When it was finally signed into law in 1965, its blank-checkedness was in part to get the AMA (and private insurers) to not resist too strenuously. Since then, changes in benefits have been minimal (this book does not cover the passage of Medicare Part D, just the electoral posturings leading up to it). While a very popular program, and while some survey wordings indicate people would pay more for the program, its trust fund structure has subjected it to numerous fiscal crises which provided opportunities to restructure the program's administration. Most of this occurred in a bipartisan fashion out of public view, however, the addition (and rescinding) of catastrophic insurance and then the addition of HMOs were all the result of increasingly polarized party politics and competing visions for Medicare's future.

There were several surprises to me. First and foremost, if this guy is to be believed and assuming I understood him correctly, all of the major savings wrung out of Medicare over the decades have been directly the result of it becoming more and more single-payer like and more and more regulated -- and some of these stepwise changes have occurred simultaneously with "marketlike" reforms a la the Contract on America's addition of HMOs. We're really a lot more like the Europeans and other developed nations than we think we are. The difference is not whether we can run a single-payer, highly regulated program in a cost-controlled, satisfactory fashion; the question is who do we choose to cover under that program.

The second surprise was the consistency of opposition to Medicare by politicians like Bob Dole, who opposed it in 1965 and tried to dismantle it three decades later. There are some priceless quotes in this book from people like Newt Gingrich, saying they expect Medicare to whither away as everyone switches to private insurers. Not likely, and furthermore, anyone who gives this any thought at all would realize that letting the privates cherry pick will just raise costs overall with no meaningful increase in benefits across the board. Utter insanity.

The third surprise was how come Medicare covers what it does and doesn't cover what it doesn't (specifically, why a prescription drug benefit was so slow in arriving, and crappy when it did appear, and why there still isn't a long-term care benefit under Medicare). The people who crafted Medicare at the beginning really hoped and expected this to be a wedge that became national health insurance that would ultimately include long-term care, prescription drugs, etc. But because cost containment was always so enormously problematic, benefits creep didn't happen, much less major extension of benefits to new categories of people/new categories of treatment (with the exception of end stage renal disease; that was an interesting little anecdote as well).

It's academic. It's wonky. It lacks narrative thrust, even tho it is mostly organized chronologically. But it is fantastically good. Should you read it? If you're interested in politics in this country, this ought to be on your list somewhere.

common question: does T. know what to expect?

I got a lot of different questions when I was pregnant with T., and had a policy of stock-detailed-answer-to-forestall-more-questions. But this particular question has me a bit flummoxed. People ask some variation on whether or not we've talked to T. about the arrival of A. in the near future.

So far, since the people asking are people who know us relatively well, I've been giving a fairly detailed but open-ended answer. Well, we've told him, but he's not that verbal so it's really hard to tell how much he understands. [pause for a beat or two] Besides, _we_ know we're going to be surprised, so the whole idea that he could possible be prepared for this seems a bit unlikely, right?

This usually gets a chuckle and a isn't-that-the-truth (which is the goal), but not always. There's a certain contingent out there that talks about classes and/or books for older siblings. This has me scratching my head. I mean, he just turned 3. If you tell him you're going for a ride in the car in a couple hours, he goes out to the car _now_ and gets pissy if you aren't ready to leave. The future, as a concept, may be present in that adorable little head, but I can't seem to connect with it yet.

I asked R. what he remembered, since he's the oldest of four. I only have one younger sister, and she's a 1 year and 10 months after me, so (to me, obviously) I have no recollection of her not being around. I _do_ have vague recollections of her being too young to play with, but that could have been when she was as old as two -- who knows? But R.'s youngest sibling -- a brother -- is 9 years younger. Surely he remembers C.'s last pregnancy. Right?

Nope. He remembers his parents going to the hospital and coming home with J. But unless my husband is lying to me, that's pretty much the whole story.

What the heck to do with 4 pages of advice along these lines?

T. _has_ been coming to prenatals with me, altho NOT to the one time I had a sonogram because they were absolutely clear that they did not want other children present at the genetics counseling/ultrasound/amnio appointment. And that was the only sonogram. T. is usually nursing (or trying to nurse) when I lay down at the birth center to be measured, doptoned etc. He finds the tape measure vastly entertaining, my belly button is a constant source of amusement, and when he gets ahold of the lube he cackles with glee. Does he have any mortal clue when I tell him there's a baby in there, his sister, her name, that he shouldn't hit or press on my belly?

We don't _have_ a nursery, so all that crap is irrelevant. We did get a new futon on the floor (a twin) complete with Backyardigans sheets etc. I cannot even begin to imagine having T. pick out sheets ordered online. That just seems drastically unlikely. His primary interest in my laptop his pressing the power button, altho there are a couple of buttons on the side and where the charger plugs in that are almost as entertaining.

But easily the most daunting aspect of this advice is here:

"Instill in your children, especially toddlers, that babies are not like dolls – their moods are like a seesaw, one minute they are content, the next fussy and temperamental."

Are you shitting me? They are _seriously_ expecting me to discuss with my toddler the emotional lability of an as-yet-unborn third party? I have yet to connect with T. on the subject of _his_ moods, _MY_ moods or his papa's moods. And this is not for lack of trying. We all get the idea of owie. I _think_ we all understand tired. We may understand hungry and thirsty, at least operationally. I've labeled like crazy all along (you seem sad, you are angry, etc.). No indication that any of this is getting through at all. I figured things were going great because finally, today, he pointed and tracked and verbally labeled _all at once_. And _that_ involved something really easy to understand: his papa returning to the van at the transfer station.

On one level, I'm inclined to point to his papa as a data point: see? _He_ didn't notice when he was _9_. Trying to get through to his 3 year old offspring is a pointless waste of time. You could take it further; attempting to discuss subtleties of mood with R. is often a dodgy proposition. But I can't help but wonder. Are there _any_ toddlers that this works with? _Who_?

I'd love to hear all your tales of your precociously emotionally intelligent young 'uns. And how old they were when you could reasonably expect them to understand someone else's instability of mood. Particularly a someone who hadn't been born yet.

Oh, and this is all complicated by the fact that T. won't play with stuffed animals, puppets, dolls, etc. It's not that we don't have them. It's just that he's completely uninterested. Well, not completely. There's a thing I do with the cow puppet that can make him fall over he laughs so hard. It involves attacking him with cow-kisses, backing off, and then throwing the cow puppet at his head while saying, "MOOOOO!" quite loudly. He'll bring the cow puppet back for more, sometimes for fifteen minutes at a time. But you can play a similar game with a pillow or a very light ball, without the kisses or the mooing, just by throwing things at his head.

ETA: Only light, non-dangerous things. We're not _that_ crazy around here.

ETA2: I'm thinking these people are just dealing with a different species of toddler from T.

We got T. a drinks-and-pees anatomically "correct" boy doll a long time ago. He has on-and-off played with the doll, mostly to explore aspects of the doll that we strenuously objected to him doing to us (opening and closing our eyelids, for example). We figured this was a plausible use for the toy. Reversing that now seems, um, nuts. Yeah, I'll go with nuts. *sigh* I guess the good news is that T. _does_ understand the word gentle, altho he often is perfectly happy to defy that as a directive.

ETA3: Yeah, the site is crap. Here's yet another effort:

This one starts strong, but you can tell it's not going to work for me with the cosleeping, bf-ing mother is weaning her one year old when she's pregnant with the second. I don't have it that together, or I wouldn't still be nursing a 3 year old while pregnant with the second. I would not be observing his predictable 2 a.m. switch from his new bed to the old bed I'm sleeping in. He doesn't even seem to wake up fully to make this switch -- but it happens at the same time to within fifteen minutes. Amazing how fast that pattern set up; suggests that breaking it is going to be all but impossible. Things really go downhill in this article when the bottles show up and the toddler is helped to feed a doll, preparatory to helping with the infant. Yeah, that's going to happen. And then, the fucking sibling classes are mentioned once again. I particularly liked this bit tho:

"Finally, when the big day comes, try not to leave without saying "goodbye," says Dr. Noll. "Even if Mom has to leave in the middle of the night, it's better to let the child know what is going on, that you're OK and that you'll be home soon," she says."

_That'd_ definitely be a winner. Not. Odds on, he'll be coming with us to the birth center while we frantically call 'round to find someone to meet us there and take him elsewhere, either back home or to their house or whatever, depending on which person in the call tree is available when. But if in some perfect world, that someone arrives before we depart, I'm not freaking waking that kid up. Dude. That is insane.

ETA4: There are a many, many more articles on that topic at that website. In addition to the strange and incomprehensible advice, they consistently warn about regression and aggression, which makes me kind of suspicious. What the hell good is all this preparation doing, if you get the same outcome anyway? I'm thinking this is cargo-cultism. With few exceptions, all the good parents I know, whether they prepped their kids or not, had to deal with a certain amount of jealousy/acting out/whatever when the new baby showed up and monopolized one or both parents' time and energy. What's the point?