In “The Quest to Belong” Mr. Cohen says opportunity is the bright star of the immigrant story. Its black sun is displacement and loss. Prof. Krugman addresses “Obamacare’s Secret Success” and says follow the bending cost curve and you will find that the slowdown in health costs has been dramatic. Here’s Mr. Cohen:
With a grandchild about to be born in Atlanta, another on the way in Ho Chi Minh City, I have been thinking about the beginning of the family odyssey; of my great-grandfather, Isaac Michel, and his decision to leave the shtetl in northern Lithuania and head south from Russian pogroms toward the sun, the ostrich feathers, the gold and the promise of South Africa.
I imagine his first sight of Africa in 1896 after the two-week crossing: the teeming dock at Cape Town; the bundles borne all the way from Lithuania; a sea of people — black and white and brown — moving between crates piled on the quayside. Table Mountain traces a line so flat it seems an apparition. Colors have intensified, scale grown. In the shtetl everything was circumscribed. Wonders had to be willed from the trance of religious devotion. Here the very earth is exuberant. There are peaks that reach to the heavens.
In the first volume of “Jewish Migration to South Africa: Passenger Lists from the UK 1890-1905,” I find a reference to I. Michel from Siauliai (Shavel to the Jews) in Lithuania. He traveled, aged 19, on the Doune Castle, departing from England on Aug. 16, 1896. He listed his occupation as “prospector.” A great number of the East European Jews making their way to South Africa between the 1880s and 1914 were Litvaks; many of them passed, like my great-grandfather, through the Poor Jews’ Temporary Shelter at 82 Leman Street in London’s East End, established in 1885 to ease the passage of Jewish trans-migrants from Eastern Europe to South Africa.
Michel, arriving penniless, started out as a peddler. He became a retail magnate. He died on an urban estate in Johannesburg with its arboretum and fish pond and aviary, surrounded by African houseboys and gold-inlaid bibelots, his black, fish-tailed Cadillac parked in the beautiful curving driveway.
Immigration is reinvention. Lands of immigrants excise the anguish of the motherland. They invite the incomer to the selective forgetfulness of new identity.
Michel, my mother’s grandfather, would not have been surprised by the idea of far-flung descendants, even if Vietnam might have raised an eyebrow. This prospector understood opportunity, chance encounter — life as action and risk. Like millions of Jews around the dawn of the 20th century he embraced emancipation to plunge from shtetl and ritual immemorial into the Sturm und Drang of the modern world. The upheaval would prove cataclysmic in Europe. My family skirted the horror.
New opportunity is only one side of the immigrant story, its bright star. The other side, its black sun, is displacement and loss. Among Michel’s children and grandchildren and great-grandchildren, in each uprooted generation on the move to Britain and Israel and the United States, there have been sufferers from manic-depression unable to come to terms with the immense struggle involved in burying the past, losing an identity and embracing a new life — as if bipolarity were just that, a double existence attempting to bridge the unbridgeable.
If you dig into people who are depressed you often find that their distress at some level is linked to a sense of not fitting in, an anxiety about where they belong: displacement anguish.
Give thanks in this holiday season for belonging, for community (that lovely word). Invite the stranger in. Make friends a garden, my mother liked to say, and let it bloom.
Turning time’s arrow around I have journeyed backward through South Africa to Lithuania. During the voyage I found unpublished journals written in Hebrew by another great-grandfather, Shmuel Cohen, who also left Lithuania for Johannesburg more than a century ago.
One of his journals begins: “The ‘Book of Man’ includes many chapters. Those speaking of others I have learned well. The first, speaking of my own character traits, I have learned but do not know.”
He goes on: “From the very first day that man is old enough to think for himself he commences collecting materials and building blocks, to establish his fort on strong foundations; to be able to rest in it securely in days to come. Working himself continuously eventually he falls under the burden — just as stones piled incorrectly may tumble down.
“While assured in himself, declares he thus ‘I am supreme above all creatures,’ imposing himself over others; similarly, nations boast, ‘You have chosen us from all others,’ only leading to acts of hostility against their fellow nations.
“Oh, if only awareness came unto man and he truly knew that all of creation — from the sand granule to the shining star — is connected like one chain.”
One chain: A wonderful translation of the journals was provided to me by another great-grandchild of Isaac Michel, a cousin in Israel who has found serenity in a return to Orthodoxy. His sister, like my mother, suffered the torment of manic-depression.
Be free. Belong. Do not forget. Link the chains that made you.
Now here’s Prof. Krugman:
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn’t real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that “the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.” But such expert views were largely ignored.
So, how’s it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don’t know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don’t know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita — that is, total spending adjusted for overall inflation and population growth — has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is the still-depressed economy, which might be causing people to forgo expensive medical care. But this explanation turns out to be problematic in multiple ways. For one thing, the economy had stabilized by 2010, even if the recovery was fairly weak, yet health costs continued to slow. For another, it’s hard to see why a weak economy would have more effect in reducing the prices of health services than it has on overall inflation. Finally, Medicare spending shouldn’t be affected by the weak economy, yet it has slowed even more dramatically than private spending.
A better story focuses on what appears to be a decline in some kinds of medical innovation — in particular, an absence of expensive new blockbuster drugs, even as existing drugs go off-patent and can be replaced with cheaper generic brands. This is a real phenomenon; it is, in fact, the main reason the Medicare drug program has ended up costing less than originally projected. But since drugs are only about 10 percent of health spending, it can only explain so much.
So what aspects of Obamacare might be causing health costs to slow? One clear answer is the act’s reduction in Medicare “overpayments” — mainly a reduction in the subsidies to private insurers offering Medicare Advantage Plans, but also cuts in some provider payments. A less certain but likely source of savings involves changes in the way Medicare pays for services. The program now penalizes hospitals if many of their patients end up being readmitted soon after being released — an indicator of poor care — and readmission rates have, in fact, fallen substantially. Medicare is also encouraging a shift from fee-for-service, in which doctors and hospitals get paid by the procedure, to “accountable care,” in which health organizations get rewarded for overall success in improving care while controlling costs.
Furthermore, there’s evidence that Medicare savings “spill over” to the rest of the health care system — that when Medicare manages to slow cost growth, private insurance gets cheaper, too.
And the biggest savings may be yet to come. The Independent Payment Advisory Board, a panel with the power to impose cost-saving measures (subject to Congressional overrides) if Medicare spending grows above target, hasn’t yet been established, in part because of the near-certainty that any appointments to the board would be filibustered by Republicans yelling about “death panels.” Now that the filibuster has been reformed, the board can come into being.
The news on health costs is, in short, remarkably good. You won’t hear much about this good news until and unless the Obamacare website gets fixed. But under the surface, health reform is starting to look like a bigger success than even its most ardent advocates expected.