A cinematic story of love, style, courage, family and friendship, shot by Oliver Hadlee Pearch and Carlos Nazario on the streets of Brooklyn, capturing our cover star Adesuwa Aighewi.
Adesuwa wears dress Givenchy. Earrings Alexander McQueen.
Jan wears coat and trousers MSGM. Shirt Jil Sander. Belt Giorgio Armani. Jewellery model’s own. Shoes Balenciaga.
It takes only a glance at a hospital bill or at the myriad choices you may have for health care coverage to get a sense of the bewildering complexity of health care financing in the United States. That complexity doesn’t just exact a cognitive cost. It also comes with administrative costs that are largely hidden from view but that we all pay.
Because they’re not directly related to patient care, we rarely think about administrative costs. They’re high.
A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs.
Such costs aren’t all bad. Some are tied up in things we may want, such as creating a quality improvement program. Others are for things we may dislike — for example, figuring out which of our claims to accept or reject or sending us bills. Others are just necessary, like processing payments; hiring and managing doctors and other employees; or maintaining information systems.
That New England Journal of Medicine study is still the only one on administrative costs that encompasses the entire health system. Many other more recent studies examine important portions of it, however. The story remains the same: Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.
Using data from 2010 and 2011, one study, published in Health Affairs, compared hospital administrative costs in the United States with those in seven other places: Canada, England, Scotland, Wales, France, Germany and the Netherlands.
At just over 25 percent of total spending on hospital care (or 1.4 percent of total United States economic output), American hospital administrative costs exceed those of all the other places. The Netherlands was second in hospital administrative costs: almost 20 percent of hospital spending and 0.8 percent of that country’s G.D.P.
At the low end were Canada and Scotland, which both spend about 12 percent of hospital expenditures on administration, or about half a percent of G.D.P.
Hospitals are not the only source of high administrative spending in the United States. Physician practices also devote a large proportion of revenue to administration. By one estimate, for every 10 physicians providing care, almost seven additional people are engaged in billing-related activities.
It is no surprise then that a majority of American doctors say that generating bills and collecting payments is a major problem. Canadian practices spend only 27 percent of what U.S. ones do on dealing with payers like Medicare or private insurers.
Another study in Health Affairs surveyed physicians and physician practice administrators about billing tasks. It found that doctors spend about three hours per week dealing with billing-related matters. For each doctor, a further 19 hours per week are spent by medical support workers. And 36 hours per week of administrators’ time is consumed in this way. Added together, this time costs an additional $68,000 per year per physician (in 2006). Because these are administrative costs, that’s above and beyond the cost associated with direct provision of medical care.
In JAMA, scholars from Harvard and Duke examined the billing-related costs in an academic medical center. Their study essentially followed bills through the system to see how much time different types of medical workers spent in generating and processing them.
At the low end, such activities accounted for only 3 percent of revenue for surgical procedures, perhaps because surgery is itself so expensive. At the high end, 25 percent of emergency department visit revenue went toward billing costs. Primary care visits were in the middle, with billing functions accounting for 15 percent of revenue, or about $100,000 per year per primary care provider.
“The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a co-author of the study and a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”
Costs related to billing appear to be growing. A literature review by Elsa Pearson, a policy analyst with the Boston University School of Public Health, found that in 2009 they accounted for about 14 percent of total health expenditures. By 2012, the figure was closer to 17 percent.
One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.
OTTAWA — Nine years before Rosa Parks refused to give up her seat on a Jim Crow-era bus in Montgomery, Ala., Viola Desmond tried to sit in a whites-only section of a movie theater in New Glasgow, Nova Scotia.
Ms. Desmond, a businesswoman who had her own line of cosmetics and who died in 1965, was prosecuted for trying to defraud the provincial government of 1 cent — the difference in sales tax for a seat in the balcony, where blacks were expected to sit and the whites-only ground floor ticket price. While she offered to pay the tax, she was convicted and fined 26 Canadian dollars, including court costs, at a trial at which the theater owner acted as the prosecutor and she was without a lawyer.
Now she is about to become the first black person — and the first woman other than a British royal — to appear alone on Canadian currency. The new series of $10 bills is to be released this year.
“Outside of the Underground Railroad story, which has a fair amount of mythologizing around it, Canadians do not know about black Canadian history,” said Barrington Walker, a history professor at Queen’s University in Kingston, Ontario. “Black history was imagined as not central to the founding of the country.”
Underscoring Mr. Walker’s point, Ms. Desmond’s story was little known in Canada until her sister, Wanda Robson, began drawing attention to it after taking a course in 2003 on race relations. Ms. Robson, who unveiled the design of the bank note last Thursday in Halifax, Nova Scotia, was 73 at the time of her studies at University College of Cape Breton in Nova Scotia, the sisters’ home province.
Two political scientists specializing in how democracies decay and die have compiled four warning signs to determine if a political leader is a dangerous authoritarian:
1. The leader shows only a weak commitment to democratic rules. 2. He or she denies the legitimacy of opponents. 3. He or she tolerates violence. 4. He or she shows some willingness to curb civil liberties or the media.
“A politician who meets even one of these criteria is cause for concern,” Steven Levitsky and Daniel Ziblatt, both professors at Harvard, write in their important new book, “How Democracies Die,” which will be released next week.
“With the exception of Richard Nixon, no major-party presidential candidate met even one of these four criteria over the last century,” they say, which sounds reassuring. Unfortunately, they have one update: “Donald Trump met them all.”
A survey that year found that the Venezuelan public overwhelmingly believed that “democracy is always the best form of government,” with only one-quarter saying that authoritarianism is sometimes preferable. Yet against their will, Venezuelans slid into autocracy.
“This is how democracies now die,” Levitsky and Ziblatt write. “Democratic backsliding today begins at the ballot box.”
We tend to assume that the threat to democracies comes from coups or violent revolutions, but the authors say that in modern times, democracies are more likely to wither at the hands of insiders who gain power initially through elections. That’s what happened, to one degree or another, in Russia, the Philippines, Turkey, Venezuela, Ecuador, Hungary, Nicaragua, Sri Lanka, Ukraine, Poland and Peru.
Venezuela was a relatively prosperous democracy, for example, when the populist demagogue Hugo Chávez tapped the frustrations of ordinary citizens to be elected president in 1998.
Likewise, the authors say, no more than 2 percent of Germans or Italians joined the Nazi or Fascist Parties before they gained power, and early on there doesn’t seem to have been clear majority support for authoritarianism in either Germany or Italy. But both Hitler and Mussolini were shrewd demagogues who benefited from the blindness of political insiders who accommodated them.
Let me say right here that I don’t for a moment think the United States will follow the path of Venezuela, Germany or Italy. Yes, I do see in Trump these authoritarian tendencies — plus a troubling fondness for other authoritarians, like Vladimir Putin in Russia and Rodrigo Duterte in the Philippines — but I’m confident our institutions are stronger than Trump.
It’s true that he has tried to undermine institutions and referees of our political system: judges, the Justice Department, law enforcement agencies like the F.B.I., the intelligence community, the news media, the opposition party and Congress. But to his great frustration, American institutions have mostly passed the stress test with flying colors.
“President Trump followed the electoral authoritarian script during his first year,” Levitsky and Ziblatt conclude. “He made efforts to capture the referees, sideline the key players who might halt him, and tilt the playing field. But the president has talked more than he has acted, and his most notorious threats have not been realized. … Little actual backsliding occurred in 2017.”
That seems right to me: The system worked.
For all my confidence that our institutions will trump Trump, the chipping away at the integrity of our institutions and norms does worry me. Levitsky and Ziblatt warn of the unraveling of democratic norms — norms such as treating the other side as rivals rather than as enemies, condemning violence and bigotry, and so on. This unraveling was underway long before Trump (Newt Gingrich nudged it along in the 1990s), but Trump accelerated it.
Live music. Free T-shirts. A “Fweedom” celebration with mystery prize boxes worth up to $500, and a shot at a behind-the-scenes tour. Marijuana legalization arrives Monday in California with lots of hoopla, but only a handful of cities will initially have retail outlets ready to sell recreational pot. By Thursday afternoon, California had issued only 42 retail licenses. Another 150 applications were pending, and regulators planned to work a second straight weekend to review them. Los Angeles and San Francisco were late to approve local regulations, meaning no recreational pot shops there will open their doors Monday.
The lucky few outlets with licenses — mainly in San Diego, the Bay Area, the Palm Springs area and Santa Cruz — think they have an edge being first out of the gate.
But excitement about California joining the growing list of states and Washington, D.C., with legal recreational weed is tempered with the stresses of ensuring shelves are stocked in the face of uncertain demand. The state issued its first 20 retail licenses two weeks ago and an additional 22 have trickled out since, some for already established medical marijuana businesses that have thrived in California for two decades and will continue.
Alex Traverso, a spokesman for the California Bureau of Cannabis Control, said a dozen employees were vetting applications to “issue as many licenses as we can” in the coming days.
The temporary permits represent just a sliver of the thousands of licenses expected to eventually be issued for retail recreational sales. Local permits are a prerequisite for the state licenses, and many cities — including Los Angeles, San Francisco and Long Beach — have yet to issue any local rules, putting huge swaths of the state on the sidelines for opening day. The Palm Springs area had nine of the state’s first retail licenses, including seven in Cathedral City, population 54,000.
San Diego had eight. Santa Cruz and San Jose had four each, and others were scattered around the Bay Area and the state’s northern reaches. An outlet known as Caliva in San Jose is promoting the “Fweedom” celebration Monday with the prize boxes and exclusive tours of its growing areas, along with massages, acupuncture, waffle desserts and music with “mellow beats.”
A county supervisor will attend a 7 a.m. ribbon-cutting ceremony at Kind Peoples in Santa Cruz. Its chief executive, Khalil Moutawakkil, said pot has long been “a huge part” of the culture of the oceanfront college town.
Berkeley Patients Group, which opened as a medical marijuana dispensary in 1999 and has received a permit for recreational sales, expects lines around the block to mark opening day. The mayor of the city is expected at a ribbon-cutting ceremony at 6 a.m.
“You’ll see the people who have been consumers for decades and they were for legalization back in the ’60s,” said Sean Luse, chief operating officer. “But you’re also going to see a more mainstream group of people who were waiting for the green light.”
Harborside is planning brass bands at its locations in Oakland and San Jose, with flags and T-shirts for the first 100 people in line.
A few outlets with recreational licenses are passing on the hoopla.
For them, excitement at being first out of the gate is tempered with the stresses of complying with new regulations. Golden State Greens, with a modest storefront amid car repair shops and budget hotels in San Diego, houses a bustling business that has sold marijuana for medical purposes since 2015. It will open its doors at 7 a.m. Monday, like it does every other day of the year.
After California voters approved recreational weed last year, the shop changed its name from Point Loma Patients Consumer Cooperative, reflecting its ambitions for a broader clientele. “We’re planning for the worst and hoping for the best,” said Adam Knopf, its chief executive. “There are a lot of unknown factors but we’re prepared.”
Gary Cherlin, chief executive of Desert Organic Solutions Collective in North Palm Springs, received holiday news of his recreational sales permit as he devised promotional packages with hotels aimed at tourists who come for warm winters. He said being among the first shops to sell recreational pot means less competition.
“I don’t know how many more are coming but they don’t have a lot of time left,” he said.
Mount Shasta Patients Collective, which opened three years ago in the northern part of the state as a medical dispensary, has already turned away people coming for recreational pot.
Others with medical marijuana cards have been stocking up ahead of price increases expected after recreational weed is legal.