It’s ironic how much English permeates the Chinese culture and yet, how nationalist the students feel. They wear T-Shirt’s with American words like “Cutie” or “Kobe”, they subscribe to magazines where it’s trendy to have English titles, and they terminate conversations with “bye-bye”. Yet, when asked about the future, most students say China will surpass America in the next 5-10 years.
Taxi drivers tell me about the people they know. People that went abroad but now are back because they “love the Chinese culture” and “couldn’t cope with a western one”. Yet, in the same breath, they convey envy for the opportunities I have as a Chinese American. Perhaps I generalize the Chinese as they generalize me but today, I feel this country’s irony.
Friday, December 19, 2008
Monday, December 15, 2008
Thursday, December 11, 2008
Concerning the Uninsured
18% of the US population is currently uninsured. Though Medicaid commonly covers women and children, 28% of people ages 18-25 are still uninsured and anomalies exist because 64% of uninsured individuals have full time/full year jobs. The consequences of being uninsured is that these people are more likely to get reasonable coverage when they are sick. Thus, the uninsured tend to use more clinics and ER services, postpone care, fail to pick up prescriptions, and use less preventative services (Institute of Medicine Report). It has been shown that the uninsured tend to get diagnosed for chronic diseases too late and they are thus more likely to die of diseases such as cancer. In fact, the uninsured have 25% higher mortality rate then the insured- leading to 20,000 excess deaths per year. Given all this, it’s certain that we have to find a way to cover the uninsured in the US. I don’t really know how. However, I can discuss what we shouldn’t do and also, some suggestions as to where to start.
First, we have to note that there are clear differences between the personalities of those insured verses those uninsured. The insured tend to seek medical care more frequently while the uninsured tend to be more like population on Medicaid- poorer, less self sufficient, and underrepresented. Second, it is important to look at why people are uninsured: 64% say insurance is too expensive, many cite employer related reasons, and some even say they don’t want/don’t need it. About 1% of people simply are too sick to get insurance. In terms of not being able to acquire health insurance, it is understandable. A family of 2 may make only $10,000 per year which is around the annual cost for insurance so for the poor, there is a tradeoff between medical care and basic living needs. Thus, a simple way of providing coverage is to increase the income poverty line.
Third, people are not charged their individual average costs. Rather they are charged the group’s average cost so insurance often have a “high administrative” load for young, healthy workers. Also, since people know there are safety nets available to give them free care, a free loader problem could exist and contribute to current rates of uninsured (Feldstein Chapter 7). Finally, some of the insured are likely crowded out of private coverage because they drop coverage for free care. This happens when people opt into public programs such as Medicaid because it’s free even if the quality is worse.
In solving all these problems, there are also two political constraints. First, we are unlikely to get rid of private insurance which has very concentrated interests with over $500 billion in revenues. Workers in large firms are thus very content with their health insurance and are resistant to change. Second, the government faces enormous fiscal pressure. Social Security and Medicare will go unfunded soon and the federal budget has been in deficit for 30 years.
Possible solutions include expanding Medicaid, creating tax subsidies for group and non-group insurance, instilling an employer/individual mandate, or establishing universal access. Issues, however, arise with all these solutions. First, pubic expansion may be taken up by previously insured instead of the uninsured and employers may reduce/drop coverage. Take up rate is 10-70% while crowd-out can be as large as 50% so this is ineffective. However, the size of benefits and providing good information may help and simulations by Holahan and Zedlewski show that Medicaid expansions can reduce the number of uninsured. Second, tax subsidies for employers are tricky and not very elastic. Small employers may benefit but on the other hand, reducing tax subsidies hurts too. Take up rate may decline when workers have to share higher cost of health insurance and take up rate does not go up when net premium prices are lowered. Finally, individual mandates requires everyone to get health insurance with the government subsiding the process. Massachusetts tried this and failed. Even though they had a low uninsured population, government subsidies for the working poor were high.
I’m not sure where we go from here, but I know that we have to learn from our successes and failures. Good information is a must and we have to keep in mind that government actions may worsen effects but having health insurers compete on the basis of risk-adjusted premiums is desirable (Feldstein Chapter 7). Maybe the solution lies in having a national health insurance program that would eliminate high overhead and profits while making it possible to set and enforce overall spending limits. Still, I can’t argue for a best way to cover all of the uninsured in the US. I’m not sure this is even possible.
First, we have to note that there are clear differences between the personalities of those insured verses those uninsured. The insured tend to seek medical care more frequently while the uninsured tend to be more like population on Medicaid- poorer, less self sufficient, and underrepresented. Second, it is important to look at why people are uninsured: 64% say insurance is too expensive, many cite employer related reasons, and some even say they don’t want/don’t need it. About 1% of people simply are too sick to get insurance. In terms of not being able to acquire health insurance, it is understandable. A family of 2 may make only $10,000 per year which is around the annual cost for insurance so for the poor, there is a tradeoff between medical care and basic living needs. Thus, a simple way of providing coverage is to increase the income poverty line.
Third, people are not charged their individual average costs. Rather they are charged the group’s average cost so insurance often have a “high administrative” load for young, healthy workers. Also, since people know there are safety nets available to give them free care, a free loader problem could exist and contribute to current rates of uninsured (Feldstein Chapter 7). Finally, some of the insured are likely crowded out of private coverage because they drop coverage for free care. This happens when people opt into public programs such as Medicaid because it’s free even if the quality is worse.
In solving all these problems, there are also two political constraints. First, we are unlikely to get rid of private insurance which has very concentrated interests with over $500 billion in revenues. Workers in large firms are thus very content with their health insurance and are resistant to change. Second, the government faces enormous fiscal pressure. Social Security and Medicare will go unfunded soon and the federal budget has been in deficit for 30 years.
Possible solutions include expanding Medicaid, creating tax subsidies for group and non-group insurance, instilling an employer/individual mandate, or establishing universal access. Issues, however, arise with all these solutions. First, pubic expansion may be taken up by previously insured instead of the uninsured and employers may reduce/drop coverage. Take up rate is 10-70% while crowd-out can be as large as 50% so this is ineffective. However, the size of benefits and providing good information may help and simulations by Holahan and Zedlewski show that Medicaid expansions can reduce the number of uninsured. Second, tax subsidies for employers are tricky and not very elastic. Small employers may benefit but on the other hand, reducing tax subsidies hurts too. Take up rate may decline when workers have to share higher cost of health insurance and take up rate does not go up when net premium prices are lowered. Finally, individual mandates requires everyone to get health insurance with the government subsiding the process. Massachusetts tried this and failed. Even though they had a low uninsured population, government subsidies for the working poor were high.
I’m not sure where we go from here, but I know that we have to learn from our successes and failures. Good information is a must and we have to keep in mind that government actions may worsen effects but having health insurers compete on the basis of risk-adjusted premiums is desirable (Feldstein Chapter 7). Maybe the solution lies in having a national health insurance program that would eliminate high overhead and profits while making it possible to set and enforce overall spending limits. Still, I can’t argue for a best way to cover all of the uninsured in the US. I’m not sure this is even possible.
On Market Failure and Public Health
Regulation is about making sure the system works. This means limiting market failures like uncertainty, information asymmetry, externality (positive or negative actions of individual on society), etc. There are several ways of mitigating market failures but different interest groups hold different views making it hard for governments to intervene. First, the public interest view states that the government is suppose to protect us so they hold the government accountable for redistribution and efficiency. This is the regulatory perspective. These individuals feel that government ran monopolies are cheaper then the market driven economy and they push for the government to find ways where marginal cost is small. To a certain extent, our government buys into this view because natural resources like gas, water, etc. are controlled by the government as is the VA system, state, county, and municipal hospitals.
However, the alternative view or economic view believes that legislators just want to maximize their chances of (re)election by analyzing the cost and benefits of political support which might not be in the best interest of public health. Thus, economist think market failure is due to government failure and the government may be too power hunger to do much. They cite Medicaid and Medicare as examples: Medicaid is not open to all poor citizens and Medicare benefits the rich. Redistribution to the poor offends the middle class so the generosity of Medicare and Medicaid hints at the legislator’s ulterior motives.
Thus, we have two competing models (MCMC and CDHC) which both try to make the medical market competitive without leading to market failures. Under both models, selective contracting can be used. In MCMC, selective contracting would force hospitals to negotiate with health plans which, to a certain extent, show that the managed care system is making choices for its consumer. Under CDHC, things like Medical Saving Accounts arguably put more emphasis on the consumers and it increases price sensitivity, information, and consumer search.
Enthoven described the MCMC system as a way for sponsors like employers, government, or purchasing groups to work and overcome attempts by insurers to avoid price competition. To do this, they would establish rules of equity, select participating plans, manages enrollment process, and creates price-elastic demands. The success of this system depends on a number of high-quality, cost-effective, organized systems already in place which we do not have. Limitations are seen in historic events. For instance, according to Feinstein Chapter 20, in the 1970s, the government tried limiting rising medical prices and failed. In terms of price control, hospital rates were set based on conditions at the time of regulation. This leads to problems like changes in demand over time, cost (supply) changes, product changes, and imbalance between demand and supply when price is set too low. This resulted in up coding, and created over payments to hospitals in the early 90s when DRGs became profitable. We saw an unbundling effect where prices were shifted to unregulated sectors like long-term and post-op care. Finally, in 1997, the government laid down the Balance Budget Act (BBA) that led to payment cuts.
On the other hand, there are also limitations to the CDHC system. Consumers lack information and choices while Robinson et al. clearly showed that costs were higher in hospitals operating in more competitive environments at the local level. Left unmanaged, consumer-driven health plans may result in more technological competitions rather then price-based competition. As such, my view is that there needs to be an integrated plan. I want to see an MCMC system that creates an agency which can manage a number of competing insurance plans like HMOs so that citizens get standardized benefits. But, at the same time, as proven by Melnick et al., consumers must be made aware of the consequences of their choices. Thus, competition must be regulated such that there isn’t a “medical arms race” competition (Robinson et al) while still holding consumers liable for their choices.
However, the alternative view or economic view believes that legislators just want to maximize their chances of (re)election by analyzing the cost and benefits of political support which might not be in the best interest of public health. Thus, economist think market failure is due to government failure and the government may be too power hunger to do much. They cite Medicaid and Medicare as examples: Medicaid is not open to all poor citizens and Medicare benefits the rich. Redistribution to the poor offends the middle class so the generosity of Medicare and Medicaid hints at the legislator’s ulterior motives.
Thus, we have two competing models (MCMC and CDHC) which both try to make the medical market competitive without leading to market failures. Under both models, selective contracting can be used. In MCMC, selective contracting would force hospitals to negotiate with health plans which, to a certain extent, show that the managed care system is making choices for its consumer. Under CDHC, things like Medical Saving Accounts arguably put more emphasis on the consumers and it increases price sensitivity, information, and consumer search.
Enthoven described the MCMC system as a way for sponsors like employers, government, or purchasing groups to work and overcome attempts by insurers to avoid price competition. To do this, they would establish rules of equity, select participating plans, manages enrollment process, and creates price-elastic demands. The success of this system depends on a number of high-quality, cost-effective, organized systems already in place which we do not have. Limitations are seen in historic events. For instance, according to Feinstein Chapter 20, in the 1970s, the government tried limiting rising medical prices and failed. In terms of price control, hospital rates were set based on conditions at the time of regulation. This leads to problems like changes in demand over time, cost (supply) changes, product changes, and imbalance between demand and supply when price is set too low. This resulted in up coding, and created over payments to hospitals in the early 90s when DRGs became profitable. We saw an unbundling effect where prices were shifted to unregulated sectors like long-term and post-op care. Finally, in 1997, the government laid down the Balance Budget Act (BBA) that led to payment cuts.
On the other hand, there are also limitations to the CDHC system. Consumers lack information and choices while Robinson et al. clearly showed that costs were higher in hospitals operating in more competitive environments at the local level. Left unmanaged, consumer-driven health plans may result in more technological competitions rather then price-based competition. As such, my view is that there needs to be an integrated plan. I want to see an MCMC system that creates an agency which can manage a number of competing insurance plans like HMOs so that citizens get standardized benefits. But, at the same time, as proven by Melnick et al., consumers must be made aware of the consequences of their choices. Thus, competition must be regulated such that there isn’t a “medical arms race” competition (Robinson et al) while still holding consumers liable for their choices.
Thursday, December 4, 2008
Cathy
I'm not sure how I fell into the good graces of Cathy but I am glad for her friendship. As one of the managers of the school, Cathy's acceptance of me has opened doors in my relationship with other Chinese teachers. She's ever helpful and unlike my other friends, she has an uncanny ability to calm me. I think she understands me because she herself is from a minority tribe in China and she's been abroad many times.
I ended up telling her the whole truth....what a relief. Apparently she had already known I could speak Chinese so she was just waiting for me to tell her myself. There are parts of Cathy I'd like to be: calm, collected, at peace with reality. Yet, my young self rejects these qualities. Never-the-less, she's been a good role model/friend and I'm glad for her acceptance.
I ended up telling her the whole truth....what a relief. Apparently she had already known I could speak Chinese so she was just waiting for me to tell her myself. There are parts of Cathy I'd like to be: calm, collected, at peace with reality. Yet, my young self rejects these qualities. Never-the-less, she's been a good role model/friend and I'm glad for her acceptance.
Tuesday, November 18, 2008
Beijing
I went to Beijing last weekend with Brian and I was impressed. Beijing reminds me of L.A. with it's metropolitan feel and disparate neighborhoods. Brian and I went to the drum tower where an American was stabbed during the Olympics this year. We tried this weird yogurt drink and ended in a Japanese restaurant with Brian's friend Jared. The food was AMAZING. For 150 yuan, you can order as much sushi, beer, and other goodies you like. It was extravagant but worth the trip. After dinner, we hung out at bars and cafes till our train back to Tianjin the next morning. I'll definitely have to explore Beijing again later.
Friday, November 7, 2008
First Impressions
It's been a week since my dad left and I've been feeling a sense of loss. Though all the foreign teachers are nice, none of them are more then acquaintances. So, when Brian arrived today, I couldn't help but feel a sense of hope. Brian is not a new teacher. He's about 24 years old and from Chicago. Apparently, due to visa issues, he had to go back to the US for a month but now he's back.
My first impression of Brian is that he is strikingly handsome and the type of person who can hide his true feelings. He was nice but not warm which makes me wonder if he also has hidden secrets. When he asked me out for dinner, I quickly jumped at the chance and I was pleasantly surprised. The questions Brian asked were deep and probing and it was refreshing to discuss my views. i feel that I have found a real intellectual but only time will tell if I'm right.
My first impression of Brian is that he is strikingly handsome and the type of person who can hide his true feelings. He was nice but not warm which makes me wonder if he also has hidden secrets. When he asked me out for dinner, I quickly jumped at the chance and I was pleasantly surprised. The questions Brian asked were deep and probing and it was refreshing to discuss my views. i feel that I have found a real intellectual but only time will tell if I'm right.
Tuesday, November 4, 2008
A Note on the Foreign Staff
So my current interactions with the Chinese staff is virtually null. Hence, I'll tell you about the foreign staff. We have a very diverse group with teachers from Italy, Brazil, New Zealand, England, and of course the US and Canada. Here's a brief description of each teacher:
Paula (from Brazil); She's in her mid-30s and have been teaching in China for many years. She's slightly diabetic and her biggest dream is to start an English school for minority students.
Gerald: He's African American and I'm unsure where he's from but he speaks perfect Chinese with no accent. I find it ironic he may speak Chinese yet I may not.
John: He's in his 60's and from New Zealand. He was inspired to teach in China because of his son. As Compass (my school) is an IELTS training Center, it's nice to have John because he can teach IELTS. With the new visa laws though, John will have to go back to New Zealand every half-year because he's over the age of 60.
Thomas: He's a middle-aged Italian who has also been in China for many years. He is married and apparently his wife is pregnant. I find it ironic that English is his second language but no one questions where he was born or his English abilities.
James: My boss. He's from Britain and my impression is that he has been doing this far too long. This often makes him bitter and cynical but when it matters, he's there for you. He's in his mid 30's and spends most of his money on games/new cell phones.
Edmund and Lillian: They are a Canadian couple from Vancouver. They originally came over together under one contract so Lillian wasn't really suppose to teach. But, the school needed more foreign teachers so now, they both have full contracts. Edmund was born in Hong Kong but because he is male and old, students tend to accept him.
Paula (from Brazil); She's in her mid-30s and have been teaching in China for many years. She's slightly diabetic and her biggest dream is to start an English school for minority students.
Gerald: He's African American and I'm unsure where he's from but he speaks perfect Chinese with no accent. I find it ironic he may speak Chinese yet I may not.
John: He's in his 60's and from New Zealand. He was inspired to teach in China because of his son. As Compass (my school) is an IELTS training Center, it's nice to have John because he can teach IELTS. With the new visa laws though, John will have to go back to New Zealand every half-year because he's over the age of 60.
Thomas: He's a middle-aged Italian who has also been in China for many years. He is married and apparently his wife is pregnant. I find it ironic that English is his second language but no one questions where he was born or his English abilities.
James: My boss. He's from Britain and my impression is that he has been doing this far too long. This often makes him bitter and cynical but when it matters, he's there for you. He's in his mid 30's and spends most of his money on games/new cell phones.
Edmund and Lillian: They are a Canadian couple from Vancouver. They originally came over together under one contract so Lillian wasn't really suppose to teach. But, the school needed more foreign teachers so now, they both have full contracts. Edmund was born in Hong Kong but because he is male and old, students tend to accept him.
Saturday, November 1, 2008
First Day of Class
I'm finally teaching my own class now. Of course it's higher levels so the students are really good. We had a rocky start but after the following questions were answered, we settled into the traditional teacher/student roles.
The most common questions I get in America vs China:
In the US:
1. Where are you from?
2. Are you Mormon?
3. Have you ever been to Dallas, Texas?
4. Why did your parents name you Dallas?
In China:
1. Where are you from?
2. Where were you born?
3. Why do you look [insert Chinese, Japanese, or Korean]?
4. Do you speak Chinese? Why not?
The most common questions I get in America vs China:
In the US:
1. Where are you from?
2. Are you Mormon?
3. Have you ever been to Dallas, Texas?
4. Why did your parents name you Dallas?
In China:
1. Where are you from?
2. Where were you born?
3. Why do you look [insert Chinese, Japanese, or Korean]?
4. Do you speak Chinese? Why not?
Wednesday, October 29, 2008
Hiding
I haven't decided what to tell students when they ask about my birthplace, age, or Chinese skills. However, this was decided for me today. While introducing me to his class (which I'm currently observing), my boss told students I'm 24, born in the US, and speak no Chinese. I'm not sure yet how I feel about all this. I understand it's to protect me and my job...yet, I can't help but feel saddened. Perhaps change is about making sacrifices and I must sacrifice a part of my identity to change the bigotry here...
Tuesday, October 28, 2008
First Day
Today was my first day of training which really entails following other teachers around until I get the gist of things. I went into the office full of trepidation and having no desk, I sat alone on the couch hating myself for being early. No foreign staff was present and the Chinese staff hardly noticed my presence. Then, suddenly, a young Chinese teacher named Christina came over. She introduced herself and hoping to make a friend, I eagerly told her about myself. She then asked if I could speak Mandarin. I replied that I could speak a little at which point she asked me to demonstrate. I did but, thankfully, it was only one sentence because later, I found out she thought I shouldn’t be a foreign teacher. Apparently, my Chinese is “too good” and she thinks no one will accept me as a “foreign teacher”. Sigh.
On Racism
I’m not stupid. More then anyone, I anticipated the racism I’d face in china but it doesn’t make it easy. On the first day of school when my boss introduced me as the new ‘foreign teacher”, I witnessed critical eyes from the Chinese staff/ There were no smiles or welcoming gestures/ No questions about where I come from or who I am. Rather, a tentative “hi’ was followed by silence. In that silence I felt the divide between myself and my homeland.For the first time I wished I were white in the fullest sense of the word. Little did I know that I’d feel this way many times in the coming weeks…
Sunday, October 26, 2008
The Past and The Future
I went to the cemetery today. It was far away from Tianjin (about 2 hours drive) and really, it looked to be in the middle of nowhere. Wild chickens ran amok and dust collect on graves untended. My dad, my uncles, and my grandmother led me to my grandfather’s burial site and immediately, I was filled with grief. If he were alive, he would have been so happy to see us gathered together once again but he is not. We kowtowed to him and the other members of my family while my grandmother said a prayer. It was sad and I was desperate to forget but we cannot forget our past. My uncle cried so hard, blood sprouted from his nose. I thought it was somehow poetic that a red pool collected beneath my grandfather’s headstone. In china, red means love, it means good luck and good fortune. These are the thing my grandfather would have wished upon us and it was one more thing that brought tears to my eyes.
Later in the day, we traveled to my relative’s house. I met my grandfather’s younger brother, his wife, their son, and their granddaughter. The little girl is 8 years old and in third grade. She was really sweet. Because education is so important in china, I asked her about her schoolwork. Already, she is learning to read and write English but she doesn’t like English. She tells me that countless times, she’s cried because her schoolwork is too hard yet her parents always stress that she study. I understand her plight. To china, the young is the future and too many parents here live vicariously through their children. The sense of failure is too much for some children to bear and I felt of sense of pity for this cousin of mine.
Friday, October 24, 2008
A Long Day of Eating
I went to the seaside to eat seafood with my dad and some friends of his. I had two whole crabs and the restaurant was pretty impressive. As you enter, you are bombarded with live sea creatures of all shorts. There were three gigantic turtles bigger then my head and much more….I didn’t even know there were so many different kinds of crabs.
After lunch, we went to a flea market and it was so busy. People were everywhere and you could find just about anything. It was pretty neat but I did not buy anything (I can’t bargain and stuff at flea markets might be rip-offs).
For dinner, I ate with my family. My uncle took us to some fancy restaurant that cost more then 2,000 yuan per meal. It was Japanese I think but very well-constructed. As you enter, greeters are at the door to take you up an elevator. Then you enter a long hallway with velvet on the sides and statues of horse heads. When you come to your previously reserved room, the greeter lets you in and helps you sit. The room is impressive. A giant painting spans the ceiling and mirrors create a panoramic view. Besides the dinning table, you have a couch, a coat hanger, a side-table for the waiters, and a private bathroom. Lol.
For dinner, we had tons of food I’ve never had before. I sampled four different types of drinks and the waiters even recited a poem for us (of which I understood nothing). It was quite an experience.
Thursday, October 23, 2008
Arrival
It was a dark Wednesday evening when I arrived in
Gone are the beggars lining the streets as you exit the airport. Instead, hustlers vie for your attention. As I travel by car to the city of
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