Health Records Privacy and the Stimulus Bill (ARRA)

Americans who routinely yield up to strangers every detail of their financial status and life history to borrow money, who trust Social Security and the Internal Revenue Service with their most trusted personal information, tend to get indignant about privacy when it comes to medical records. I've puzzled about this and decided it may have to do with STD's.

Seriously, though, privacy is a big deal in the medical community. During the time I worked in a hospital environment, HIPAA provisions were more sacrosanct than anything in a Chaplain's job description. Even casual conversation in the privacy of a restroom was subject to review in case anyone in the next stall might be listening. John Halamka at Life as a Healthcare CIO summarizes how the stimulus bill handles the privacy issue. It looks to be as airtight as possible, given today's technology.

ARRA has a provision that requires covered entities keep a list of all data disclosures to third parties and provide a comprehensive audit log to patients upon request. This tracking of third party data exchange is not currently part of HIPAA requirements and will require significant enhancement to our auditing systems, our patient services reporting tools, and our personal health records which give patient access to their own audit trails.

Based on at least one interpretation of ARRA, the covered entity must take responsibility for patient notification when third parties improperly disclose patient information. There does seem to be some variation in interpretation in this area.

ARRA specifies that disclosure of a record containing a name and medical information (John Smith, Hematocrit 37) is considered a breach. Massachusetts requires the name and at least one other identifiable piece of information (John Smith, 5/23/1962, Hematocrit 37). This could have significant implications since even simple audit logs could be considered restricted/confidential information.

ARRA provides some definition about the actual notification methods required. In breaches where the contact information of more then 10 individuals is not known the covered entity must post the breach on their web site. If the breach is of more the 500 records the covered entity must make a public disclosure to “prominent” media outlets. Prior to this the only obligation was to contact the individuals directly.

ARRA also includes some language that requires covered entities limit the amount and type of information shared with providers to be the minimum required for the business need. It also requires that if patients pay for services out of pocket that covered entities provide a way for the individual to request that no information relative to the treatment be transmitted to any provider.

Privacy is foundational and we certainly cannot argue with the need to keep information confidential per patient preferences. However, some of these provisions, such as the "out of pocket" clause will be extremely challenging to implement.

Over the next few months, HITSP is working on standards which will support these ARRA provisions, including web services using XACML, WS*, and TLS.

Don't you just love those acronyms? I can follow most of them but these last three or four I will have to look up. They seem to refer to data platforms that may not share a common interface. This is the most tedious detail of information technology. We have come a long way since Apple's OS didn't work with that of Microsoft, but the same dynamic is alive and well as new creations are invented that owners wish to remain proprietary, not trusting copyright or patent laws to protect them.

H5N1 (Birtd Flu or Avian Flu) Update

The worldwide spread of the H5N1 virus continues but the mortality numbers, although still shocking, are trending downward. I have not read any opinions why this is happening, but my guess would be that a growing awareness of the dangers and nature of the disease may be more widespread as officials in affected areas increase their scrutiny. Occasional reports of officieal mass destruction of poultry flocks (chickens, ducks, geese) are certain to draw attention. Also, China and other countries have poultry vaccination policies in place.

(Most Americans are unaware, but our own poultry supply is routinely vaccinated against one or two common diseases among chickens.)

Official data from WHO list only laboratory confirmed cases, so their official numbers are low. Many more cases never get recorded because the most severe outbreaks are in what we carelessly call Third World countries.

Official record-keeping starting in 2003 reports 413 confirmed cases, of which 256 (nearly 62 percent) died.

Hat tip to Crawford Kilian for his excellent, tireless efforts at H5N1 blog.

Health Care Acronyms Crib Sheet

==►Note to newcomers: skip this first item for regular posts.◄==

IMPORTANT UPDATE!
Here is a link to an extensive list. PDF. Six or seven pages.

Will HCFA force IBNRs on your HMO’s IPA?

Perhaps no industry is more complex than healthcare. This situation is made infinitely worse through the extensive use of acronyms. Even if you don’t know an EOB from a DRG, you can resolve one of healthcare’s minor irritations by perusing ECG Management Consultants, Inc.'s list of healthcare acronyms. In this downloadable file you will find nearly 400 acronyms, from A/P to YTD.

The health care debate includes buzzwords and acronyms with more meaning to experts than laymen. This list of acronyms will remain at the top for easy access while the discussion continues, updated as I add more.
Contributions welcome.

ADVAMED == The Advanced Medical Technology Association
AHIP == America’s Health Insurance Plans
CCHIT == Certification Commission for Healthcare Information Technology
CMS == Centers for Medicare & Medicaid Services
CON == Certificate of Need
FOBs== Follow-on, or biosimilar, biologics (biotech drugs)
EHR == Electronic Health Record
HFAP == Healthcare Facilities Accreditation Program
HIMSS == Healthcare Information and Management Systems Society
HIT == health information technology
HSA == Healthcare Savings Account
ICE == In Case of Emergency
IOM == Institute of Medicine
LVN == Licensed Vocational Nurse
MedPAC == Medicare Payment Advisory Commission
MIPPA == Medicare Improvements for Patients and Physicians Act (2008)
NCVHS == The National Committee on Vital and Health Statistics
NVCA == National Venture Capital Association
OIA == Osteopathic International Alliance
OPM == Office of Personnel Management
P4P == Pay for Performance
PCIP == Primary Care Information Project (NYC)
PhRMA == The Pharmaceutical Research and Manufacturers of America
PHR == Personal Health Record (or Electronic Health Record, EHR)
PORI == Physicians’ Quality Reporting Initiative
PVBP == Physicians Value Based Purchasing
RHIO Regional Health Information Organizations (aka RHI “exchanges”)
SCHIP == State Children’s Health Insurance Program
SGR == Sustainable Growth Rate (various formulas)
XML == Extensible Markup Language


The longest and best online discussion I have found thus far is in the post and comments thread by Magie Mahar, March 1, at The Health Care Blog.
If the reader expects to understand the scope and complexity of this discussion, this is a good place to start.
Printed out it would run to over thirty pages. And it's not bullshit, either. This is serious talk among card-carrying experts about reforming health care.

Dr. Sanjay Gupta on Medical Tourism

It's only seven minutes.
Read the article, too.

Tammy Erickson -- Generations in China

This morning's best catch from Harvard Business online. Thumbnail descriptions of China's generational divides.

Tamara J. Erickson is both a McKinsey Award-winning author and popular and engaging storyteller. Her compelling views of the future are based on extensive research on changing demographics and employee values and, most recently, on how successful organizations work. Erickson has co-authored four Harvard Business Review articles and the books Retire Retirement: Career Strategies for the Boomer Generation and Workforce Crisis: How to Beat the Coming Shortage of Skills and Talent. She is with nGenera.

*Individuals born from about 1928 to 1945 (Traditionalists)
*Individuals born from about 1946 to 1960/1964 (Boomers)
*Generation X - Individuals born from about 1961/1965 to 1979
*Generation Y - Individuals born from 1980 to 1995

This snip is from her description of the Y's.

Nicknamed the "Litter Emperors," Gen Y's in China occupy a special role in the burgeoning society. China's one child policy, introduced in 1979, means that most members of this generation are only children, in many instances reared as the sole focus of two parents and four doting grandparents. They tend to have high self esteem and a level of confidence that positions them for leadership roles in China and globally.

Like many Y's around the world, this generation has strong advanced technological skills and an urge to be connected globally. Even as teens, they confidently communicate directly with outside world leadership and influence the future of their country. During the 2008 Tibetan unrest which marked the 49th anniversary of the failed 1959 Tibetan uprising against Beijing's rule, young patriotic Chinese waged Internet campaigns against Western media coverage of the protests. Also in 2008, when a massive earthquake killed 70,000, many young people participated in the rescue as volunteers.

Teen Y's in China have experienced a wave of national pride. Two foreign colonies were returned to China during their teen years: Hong Kong from Britain in 1997 and Macau from Portugal in 1999. In 2001, China was admitted into the World Trade Organization. Most significantly, in 2008, China successfully hosted the 2008 Summer Olympics.

As in India, Y's in China share this generation's global sense of immediacy, coupled with the excitement of being part of the country's first wave of broad economic opportunity and growing national pride. Y's in China are confident and competitive. For many, a desire for economic success is closely coupled with a desire for status. They are looking forward, toward increasing China's role and influence in the world.

As we look ahead to future generations, the one child policy was re-evaluated in 2008 and extended for at least another decade, insuring that the next generation will also be comprised largely of single children.

China, like other countries I'll discuss over the upcoming weeks, illustrates the dramatically different experiences and formative events that influenced those growing up in the 1940's - 1970's (the generations that I call Traditionalists and Boomers in the United States), and the growing similarity of experiences in the 1980's onward. Generations X and Y are the beginnings of global generations.

Litter Emperors! I love it.
Sounds like our own kids, acting like royalty while trashing the planet with disposable everything.

John Hope Franklin (1915-2009)

My writing is not good enough to say anything about John Hope Franklin worth remembering.
You Tube videos are already cropping up.
Here is a link to Dr. Franklin & Lea Fridman: George Washington Williams (48 minutes)
George Washington Williams was a black historian, writing in the Nineteenth Century (b. 1849), who was an inspiration and role model for Dr. Franklin.


John Hope Franklin Talks About His Decision To Become An Educator

Break time

►BACK IN A MOMENT◄
(Whatever that means)

(My part-time post-retirement job has come up with a string of assignments limiting my blogging time.)

Today's Health Care Reading - Private Care and Insurance vs Government Care and Insurance

For an overview of the public versus private debate, below are three links outlining the scope of the discussion as of this morning.

To understand this discussion the reader is reminded not to confuse providers with insurers. They are not the same.
Providers furnish the professional services and facilities that are health care.
The mission of insurance is to administer and coordinate the costs of health care.
Medicare can be thought of as government insurance. So that no one believes medical care is free, Medicare charges a premium for Part B. And to let providers understand that Medicare is not giving them a blank check to charge as much as they want, there is also a rate over which Medicare will not pay.

The "gap" between what Medicare will pay and what providers charge can be paid out of pocket by the Medicare beneficiary, or he or she can purchase private insurance, sometimes called a "medigap policy," to cover those costs in return for an additional monthly premium.

For the last four years another insurance product called Medicare Advantage has been made available through an agreement between Medicare and the insurance industry. A Medicare beneficiary can leave the Medicare system altogether to have health care needs managed by one of several alternative private plans. These plans are subsidized directly by Medicare which continues to collect the Part B premium from the beneficiary. In other words, the government still collects the money, but the beneficiary's health care is outsourced to a private insurance company and whatever providers they approve. Depending on individual plans and where the beneficiary lives, an additional premium may be charged ranging from zero to an additional amount over and above the premium already being collected by Medicare Part B.

The health care reform debate now in progress is an attempt to find a remedy for America's spiraling health care costs. Not to put too fine a point on it, in the words of a politician whose name I can't recall, America has the best health care system in the world and the worst way of paying for it. Many factors go into the reasons for this situation, but the same Yankee Ingenuity that produces history's most impressive advances in medicine also produces an equally impressive number of ways to extract the greatest possible profits from those advances, not the least of which is insurance whose mission is to manage risk pools in a manner that minimizes costs while at the same time maximizing the delivery of products and services .

"Risk pool" is defined not only by those included but by those who are excluded as well. This is where the rub comes in, because so many people are excluded from insurance risk pools that whatever health care costs they incur are ultimately covered by charity, taxes and/or higher insurance premiums.

The insured population consists of Medicare and SCHIP beneficiaries, veterans (whose health care is furnished by the Veterans Administration), members of the armed forces (whose needs are met by Tricare, formerly CHAMPUS), government employees (covered by FEHBP), Native Americans (Indian Health Service) and a large population of employed people under a host of group insurance plans that may or may not include coverage for beneficiaries.

A large uninsured population is part of the nation's medical bill. Just because they are uninsured it does not mean that their care is not a cost. In addition to receiving emergency services in accordance with the law, those who neglect non-emergency care often incur greater emergency expenses as the result of preventable complications. Add to that group several millions of others including unemployed people or those whose earnings are too low to pay for insurance, individuals with adequate incomes who are in good health but opt not to have health insurance, individuals with chronic or pre-existing conditions who are unacceptable in risk pools, and a large and growing number of Medicaid beneficiaries. The cost of medical care for uninsured Americans must be recovered either by taxes or higher charges to those who are insured.

(Even after all these years, most people still have no idea what the difference is between Medicare and Medicaid. Medicare is a form of government insurance for seniors. Medicaid is a program of financial aid - as the name indicates - for destitute people who cannot afford various social services, including medical care, provided by government. The layman's word for Medicaid is welfare. That's also where the food stamps and WIC vouchers come from. Look down your nose at your peril. There but for the grace of God you may go. Both my parents were Medicaid beneficiaries.)

Here are three readings I recommend.

►►►An All Out Solution to Healthcare Crisis by Dr. R.K. “Ravi” Pandey.

Published last December, this piece advances the argument for a three-tiered approach to universal health care.

Tier 1 would focus on the general health need as well as the wellness. The government through taxes will provide these services. The taxes will be solely collected for healthcare purposes and will be a percentage of every individual’s income. This fixed or progressive percentage of income, as tax would bring ownership to all. Also, the burden would be proportionately distributed among the rich and the poor. It will free up small businesses from the burden of worrying about healthcare and enable them to focus on the growth of their business and their most important societal contribution – creating millions of jobs. A move towards this tiered structure would free up every American from worrying about health to focus on more important things like improving their job productivity and taking care of their family. American industries will have a chance to compete in the global market on an equal footing. The economy will be invigorated and grow.

Adaptation of Tier 1 as a national program would require creation and development of the infrastructure, which will create jobs to boost the economy in construction sector.

Second and third tier would be left to the free market to design with legislative guidance. Second tier could be designed for buying insurance for serious illnesses and tier 3 could be, in Senator McCain’s terms, the Cadillac of healthcare. This would be for those who want to buy insurance for hair replacement, fertility treatment, etc. Those who want to keep themselves or their family members alive in a vegetative state for years would have to buy their coverage through tier 2 and tier 3 as appropriate. The healthcare dollars need to be utilized for overall national health. They should be prioritized for the net present value of life for the individuals competing for the resources.

This three-paragraph snip does not do justice to this piece. It addresses a host of other considerations, including the problems of not enough physicians, empowering nurses to write prescriptions as well as dental and eye care.
The comments thread is also a must-read.

►►►The Siren Song of Public Programs by Roger Collier at the Health Care Blog

This piece from January looks at the very appealing "Medicare for all" approach to universal health care and finds it filled with flaws.

It seems a seductive idea. Medicaid and its little cousin, SCHIP, provide coverage to more than forty million low-income people, most of whom would otherwise have no insurance, while Medicare is an essential part of the lives of 45 million seniors. It’s hard to imagine American health care without these programs, and understandable that there should be demands for their expansion to cover many of our forty-seven million uninsured.

Seductive it may be, but could the proposal also be the siren song that might lead to the wreck of reform?

In a few short paragraphs he hits the main reasons it is more of a dream than a reality. The comments thread is a serious discussion including input by Dr. Pandy from the first reading.
Maggie Mahar adds her excellent input, including a quick and easy to grasp reason why this would never result in savings...

A wholesale cut of doctors' fees would mean many fewer doctors would take Medicare patients-- that would be the beginning of the end for Medicare. No Democrat wants that to happen on his watch.

Anyone who cannot understand that???


►►►The Public Program Impasse: A Proposal, also by Roger Collier, advances a hot-off-the-press idea (this morning's post) which would involve compromises on the part of several interests, not the least of which is Barack Obama himself.

With current front-runner reform models all including some form of “insurance exchange,” a public program option could be written into reform legislation but implemented only when insurer premium increases for the standard coverage exceed a predetermined target, for example CPI change plus one percent. To minimize the effects of local and year-to-year aberrations and insurer premium variations, the trigger test could perhaps be applied on a biennial basis for each regional exchange, with the premium number in the comparison being a weighted average across insurers, and with the CPI percentage that for the region. This approach doesn’t cover the first year, since it’s dependent on year-to-year changes, but the Massachusetts Connector and Netherlands health care reform experiences suggest that insurers will offer aggressively low rates initially in order to build market share.

At the moment he's getting beat up a little in the comments thread, but I find the idea appealing. The language above looks like a variant on Medicare Advantage, but I can't be sure that's what it really means.

I can't get a hint how this proposal might stand on the mater of mandates. The biggest difference between Hillary Clinton's plan and Obama's plan was the matter of mandates. Hers had a mandate for all to participate. His plan was (and is, so far) optional. Young, healthy, selfish citizens who can afford insurance have an option not to participate, waiting until the day comes when medical expenses exceed their out-of-pocket comfort level. The currently in place and going broke Massachusetts plan is modeled on the mandate idea. If you live in MA you will be insured, required to pay for insurance (like that for your car), and the state will figure out some way for you to afford it.

I rather like the idea myself, if only to capture that young, healthy, income-producing population now opting to, as the insurance industry says, "go naked." I see no reason that for a buck or two in taxes per person (sin tax, lottery, payroll, whatever) individual states should not be able to get enough money to fill out public health clinics with more staff, run a little chronic-conditions and well care on the side, and subsidize low-income citizens with whatever competing private insurer is in the business.

What He Said

Visit msnbc.com for Breaking News, World News, and News about the Economy

GM Cars of the Future

With apologies to Lincoln Steffens, I have seen the future and it's damn expensive.

Top Gear GM Hy-Wire


General Motors - Sequal - Hydrogen Fuel Cell Car

Dead Palestinian babies and bombed mosques - IDF fashion 2009

Ha'aretz is not a lunatic fringe source, but like all the world's great newspapers publishes a wide range of articles and opinion pieces. I never heard of Uri Blau before today but a quick search indicates he has been looking at the corrosion of the IDF for some time.
I came across this link by accident while editing my blogroll this morning, weeding out links that no longer work, etc. I can't recall if this was via Elijah Zirwan or Salim Adil.

Dead Palestinian babies and bombed mosques - IDF fashion 2009

The office at the Adiv fabric-printing shop in south Tel Aviv handles a constant stream of customers, many of them soldiers in uniform, who come to order custom clothing featuring their unit's insignia, usually accompanied by a slogan and drawing of their choosing. Elsewhere on the premises, the sketches are turned into plates used for imprinting the ordered items, mainly T-shirts and baseball caps, but also hoodies, fleece jackets and pants. A young Arab man from Jaffa supervises the workers who imprint the words and pictures, and afterward hands over the finished product.

Dead babies, mothers weeping on their children's graves, a gun aimed at a child and bombed-out mosques - these are a few examples of the images Israel Defense Forces soldiers design these days to print on shirts they order to mark the end of training, or of field duty. The slogans accompanying the drawings are not exactly anemic either: A T-shirt for infantry snipers bears the inscription "Better use Durex," next to a picture of a dead Palestinian baby, with his weeping mother and a teddy bear beside him. [Durex is an internationally known condom brand ].A sharpshooter's T-shirt from the Givati Brigade's Shaked battalion shows a pregnant Palestinian woman with a bull's-eye superimposed on her belly, with the slogan, in English, "1 shot, 2 kills." A "graduation" shirt for those who have completed another snipers course depicts a Palestinian baby, who grows into a combative boy and then an armed adult, with the inscription, "No matter how it begins, we'll put an end to it."

There are also plenty of shirts with blatant sexual messages. For example, the Lavi battalion produced a shirt featuring a drawing of a soldier next to a young woman with bruises, and the slogan, "Bet you got raped!" A few of the images underscore actions whose existence the army officially denies - such as "confirming the kill" (shooting a bullet into an enemy victim's head from close range, to ensure he is dead), or harming religious sites, or female or child non-combatants.

In many cases, the content is submitted for approval to one of the unit's commanders. The latter, however, do not always have control over what gets printed, because the artwork is a private initiative of soldiers that they never hear about. Drawings or slogans previously banned in certain units have been approved for distribution elsewhere. For example, shirts declaring, "We won't chill 'til we confirm the kill" were banned in the past (the IDF claims that the practice doesn't exist), yet the Haruv battalion printed some last year.

The slogan "Let every Arab mother know that her son's fate is in my hands!" had previously been banned for use on another infantry unit's shirt. A Givati soldier said this week, however, that at the end of last year, his platoon printed up dozens of shirts, fleece jackets and pants bearing this slogan.

"It has a drawing depicting a soldier as the Angel of Death, next to a gun and an Arab town," he explains. "The text was very powerful. The funniest part was that when our soldier came to get the shirts, the man who printed them was an Arab, and the soldier felt so bad that he told the girl at the counter to bring them to him."

Does the design go to the commanders for approval?

The Givati soldier: "Usually the shirts undergo a selection process by some officer, but in this case, they were approved at the level of platoon sergeant. We ordered shirts for 30 soldiers and they were really into it, and everyone wanted several items and paid NIS 200 on average."

What do you think of the slogan that was printed?

"I didn't like it so much, but most of the soldiers wanted it."

Many controversial shirts have been ordered by graduates of snipers courses, which bring together soldiers from various units. In 2006, soldiers from the "Carmon Team" course for elite-unit marksmen printed a shirt with a drawing of a knife-wielding Palestinian in the crosshairs of a gun sight, and the slogan, "You've got to run fast, run fast, run fast, before it's all over." Below is a drawing of Arab women weeping over a grave and the words: "And afterward they cry, and afterward they cry." [The inscriptions are riffs on a popular song.] Another sniper's shirt also features an Arab man in the crosshairs, and the announcement, "Everything is with the best of intentions."

G., a soldier in an elite unit who has done a snipers course, explained that, "it's a type of bonding process, and also it's well known that anyone who is a sniper is messed up in the head. Our shirts have a lot of double entendres, for example: 'Bad people with good aims.' Every group that finishes a course puts out stuff like that."

When are these shirts worn?

G. "These are shirts for around the house, for jogging, in the army. Not for going out. Sometimes people will ask you what it's about."

Of the shirt depicting a bull's-eye on a pregnant woman, he said: "There are people who think it's not right, and I think so as well, but it doesn't really mean anything. I mean it's not like someone is gonna go and shoot a pregnant woman."

What is the idea behind the shirt from July 2007, which has an image of a child with the slogan "Smaller - harder!"?

"It's a kid, so you've got a little more of a problem, morally, and also the target is smaller."

Do your superiors approve the shirts before printing?

"Yes, although one time they rejected some shirt that was too extreme. I don't remember what was on it."

These shirts also seem pretty extreme. Why draw crosshairs over a child - do you shoot kids?

'We came, we saw'

"As a sniper, you get a lot of extreme situations. You suddenly see a small boy who picks up a weapon and it's up to you to decide whether to shoot. These shirts are half-facetious, bordering on the truth, and they reflect the extreme situations you might encounter. The one who-honest-to-God sees the target with his own eyes - that's the sniper."

Have you encountered a situation like that?

"Fortunately, not involving a kid, but involving a woman - yes. There was someone who wasn't holding a weapon, but she was near a prohibited area and could have posed a threat."

What did you do?

"I didn't take it" (i.e., shoot).

You don't regret that, I imagine.

"No. Whomever I had to shoot, I shot."

A shirt printed up just this week for soldiers of the Lavi battalion, who spent three years in the West Bank, reads: "We came, we saw, we destroyed!" - alongside images of weapons, an angry soldier and a Palestinian village with a ruined mosque in the center.

A shirt printed after Operation Cast Lead in Gaza for Battalion 890 of the Paratroops depicts a King Kong-like soldier in a city under attack. The slogan is unambiguous: "If you believe it can be fixed, then believe it can be destroyed!"

Y., a soldier/yeshiva student, designed the shirt. "You take whoever [in the unit] knows how to draw and then you give it to the commanders before printing," he explained.

What is the soldier holding in his hand?

Y. "A mosque. Before I drew the shirt I had some misgivings, because I wanted it to be like King Kong, but not too monstrous. The one holding the mosque - I wanted him to have a more normal-looking face, so it wouldn't look like an anti-Semitic cartoon. Some of the people who saw it told me, 'Is that what you've got to show for the IDF? That it destroys homes?' I can understand people who look at this from outside and see it that way, but I was in Gaza and they kept emphasizing that the object of the operation was to wreak destruction on the infrastructure, so that the price the Palestinians and the leadership pay will make them realize that it isn't worth it for them to go on shooting. So that's the idea of 'we're coming to destroy' in the drawing."

According to Y., most of these shirts are worn strictly in an army context, not in civilian life. "And within the army people look at it differently," he added. "I don't think I would walk down the street in this shirt, because it would draw fire. Even at my yeshiva I don't think people would like it."

Y. also came up with a design for the shirt his unit printed at the end of basic training. It shows a clenched fist shattering the symbol of the Paratroops Corps.

Where does the fist come from?

"It's reminiscent of [Rabbi Meir] Kahane's symbol. I borrowed it from an emblem for something in Russia, but basically it's supposed to look like Kahane's symbol, the one from 'Kahane Was Right' - it's a sort of joke. Our company commander is kind of gung-ho."

Was the shirt printed?

"Yes. It was a company shirt. We printed about 100 like that."

This past January, the "Night Predators" demolitions platoon from Golani's Battalion 13 ordered a T-shirt showing a Golani devil detonating a charge that destroys a mosque. An inscription above it says, "Only God forgives."

One of the soldiers in the platoon downplays it: "It doesn't mean much, it's just a T-shirt from our platoon. It's not a big deal. A friend of mine drew a picture and we made it into a shirt."

What's the idea behind "Only God forgives"?

The soldier: "It's just a saying."

No one had a problem with the fact that a mosque gets blown up in the picture?

"I don't see what you're getting at. I don't like the way you're going with this. Don't take this somewhere you're not supposed to, as though we hate Arabs."

After Operation Cast Lead, soldiers from that battalion printed a T-shirt depicting a vulture sexually penetrating Hamas' prime minister, Ismail Haniyeh, accompanied by a particularly graphic slogan. S., a soldier in the platoon that ordered the shirt, said the idea came from a similar shirt, printed after the Second Lebanon War, that featured Hassan Nasrallah instead of Haniyeh.

"They don't okay things like that at the company level. It's a shirt we put out just for the platoon," S. explained.

What's the problem with this shirt?

S.: "It bothers some people to see these things, from a religious standpoint ..."

How did people who saw it respond?

"We don't have that many Orthodox people in the platoon, so it wasn't a problem. It's just something the guys want to put out. It's more for wearing around the house, and not within the companies, because it bothers people. The Orthodox mainly. The officers tell us it's best not to wear shirts like this on the base."

The sketches printed in recent years at the Adiv factory, one of the largest of its kind in the country, are arranged in drawers according to the names of the units placing the orders: Paratroops, Golani, air force, sharpshooters and so on. Each drawer contains hundreds of drawings, filed by year. Many of the prints are cartoons and slogans relating to life in the unit, or inside jokes that outsiders wouldn't get (and might not care to, either), but a handful reflect particular aggressiveness, violence and vulgarity.

Print-shop manager Haim Yisrael, who has worked there since the early 1980s, said Adiv prints around 1,000 different patterns each month, with soldiers accounting for about half. Yisrael recalled that when he started out, there were hardly any orders from the army.

"The first ones to do it were from the Nahal brigade," he said. "Later on other infantry units started printing up shirts, and nowadays any course with 15 participants prints up shirts."

From time to time, officers complain. "Sometimes the soldiers do things that are inside jokes that only they get, and sometimes they do something foolish that they take to an extreme," Yisrael explained. "There have been a few times when commanding officers called and said, 'How can you print things like that for soldiers?' For example, with shirts that trashed the Arabs too much. I told them it's a private company, and I'm not interested in the content. I can print whatever I like. We're neutral. There have always been some more extreme and some less so. It's just that now more people are making shirts."

Race to be unique

Evyatar Ben-Tzedef, a research associate at the International Policy Institute for Counter-Terrorism and former editor of the IDF publication Maarachot, said the phenomenon of custom-made T-shirts is a product of "the infantry's insane race to be unique. I, for example, had only one shirt that I received after the Yom Kippur War. It said on it, 'The School for Officers,' and that was it. What happened since then is a product of the decision to assign every unit an emblem and a beret. After all, there used to be very few berets: black, red or green. This changed in the 1990s. [The shirts] developed because of the fact that for bonding purposes, each unit created something that was unique to it.

"These days the content on shirts is sometimes deplorable," Ben-Tzedef explained. "It stems from the fact that profanity is very acceptable and normative in Israel, and that there is a lack of respect for human beings and their environment, which includes racism aimed in every direction."

Yossi Kaufman, who moderates the army and defense forum on the Web site Fresh, served in the Armored Corps from 1996 to 1999. "I also drew shirts, and I remember the first one," he said. "It had a small emblem on the front and some inside joke, like, 'When we die, we'll go to heaven, because we've already been through hell.'"

Kaufman has also been exposed to T-shirts of the sort described here. "I know there are shirts like these," he says. "I've heard and also seen a little. These are not shirts that soldiers can wear in civilian life, because they would get stoned, nor at a battalion get-together, because the battalion commander would be pissed off. They wear them on very rare occasions. There's all sorts of black humor stuff, mainly from snipers, such as, 'Don't bother running because you'll die tired' - with a drawing of a Palestinian boy, not a terrorist. There's a Golani or Givati shirt of a soldier raping a girl, and underneath it says, 'No virgins, no terror attacks.' I laughed, but it was pretty awful. When I was asked once to draw things like that, I said it wasn't appropriate."

The IDF Spokesman's Office comments on the phenomenon: "Military regulations do not apply to civilian clothing, including shirts produced at the end of basic training and various courses. The designs are printed at the soldiers' private initiative, and on civilian shirts. The examples raised by Haaretz are not in keeping with the values of the IDF spirit, not representative of IDF life, and are in poor taste. Humor of this kind deserves every condemnation and excoriation. The IDF intends to take action for the immediate eradication of this phenomenon. To this end, it is emphasizing to commanding officers that it is appropriate, among other things, to take discretionary and disciplinary measures against those involved in acts of this sort."

Shlomo Tzipori, a lieutenant colonel in the reserves and a lawyer specializing in martial law, said the army does bring soldiers up on charges for offenses that occur outside the base and during their free time. According to Tzipori, slogans that constitute an "insult to the army or to those in uniform" are grounds for court-martial, on charges of "shameful conduct" or "disciplinary infraction," which are general clauses in judicial martial law.

Sociologist Dr. Orna Sasson-Levy, of Bar-Ilan University, author of "Identities in Uniform: Masculinities and Femininities in the Israeli Military," said that the phenomenon is "part of a radicalization process the entire country is undergoing, and the soldiers are at its forefront. I think that ever since the second intifada there has been a continual shift to the right. The pullout from Gaza and its outcome - the calm that never arrived - led to a further shift rightward.

"This tendency is most strikingly evident among soldiers who encounter various situations in the territories on a daily basis. There is less meticulousness than in the past, and increasing callousness. There is a perception that the Palestinian is not a person, a human being entitled to basic rights, and therefore anything may be done to him."

Could the printing of clothing be viewed also as a means of venting aggression?

Sasson-Levy: "No. I think it strengthens and stimulates aggression and legitimizes it. What disturbs me is that a shirt is something that has permanence. The soldiers later wear it in civilian life; their girlfriends wear it afterward. It is not a statement, but rather something physical that remains, that is out there in the world. Beyond that, I think the link made between sexist views and nationalist views, as in the 'Screw Haniyeh' shirt, is interesting. National chauvinism and gender chauvinism combine and strengthen one another. It establishes a masculinity shaped by violent aggression toward women and Arabs; a masculinity that considers it legitimate to speak in a crude and violent manner toward women and Arabs."

Col. (res.) Ron Levy began his military service in the Sayeret Matkal elite commando force before the Six-Day War. He was the IDF's chief psychologist, and headed the army's mental health department in the 1980s.

Levy: "I'm familiar with things of this sort going back 40, 50 years, and each time they take a different form. Psychologically speaking, this is one of the ways in which soldiers project their anger, frustration and violence. It is a certain expression of things, which I call 'below the belt.'"

Do you think this a good way to vent anger?

Levy: "It's safe. But there are also things here that deviate from the norm, and you could say that whoever is creating these things has reached some level of normality. He gives expression to the fact that what is considered abnormal today might no longer be so tomorrow."

What is happening to Israel?
God save us and them from ourselves.
Somebody, please tell me this is all a lie.

This story was picked up by The Guardian:

An investigation by a group of former Israeli soldiers has uncovered new evidence of the military's conduct during the assault on Gaza two months ago. According to the group Breaking the Silence, the witness statements of the 15 soldiers who have come forward to describe their concerns over Operation Cast Lead appear to corroborate claims of random killings and vandalism carried out during the operation made by a separate group of anonymous servicemen during a seminar at a military college.

Although Breaking the Silence's report is not due to be published for several months, the testimony it has received already suggests widespread abuses stemming from orders originating with the Israeli military chain of command.

"This is not a military that we recognise," said Mikhael Manekin, one of the former soldiers involved with the group. "This is in a different category to things we have seen before. We have spoken to a lot of different people who served in different places in Gaza, including officers. We are not talking about some units being more aggressive than others, but underlying policy. So much so that we are talking to soldiers who said that they were having to restrain the orders given."

Manekin described how soldiers had reported their units being specifically warned by officers not to discuss what they had seen and done in Gaza.

I rarely check the "Sphere Related Content" link that appears at the end of all my posts, but if the reader wants to see how widespread this story is, give it a look. This item is neither trivial nor obscure.

The Overton Window

Thanks to a very rational comment somewhere I learned a new term this morning - The Overton Window.
Found it at Wikipedia.

The Overton window is a concept in political theory, named after its originator, Joe Overton, former vice president of the Mackinac Center for Public Policy. It describes a "window" in the range of public reactions to ideas in public discourse, in a spectrum of all possible options on an issue. Overton described a method for moving that window, thereby including previously excluded ideas, while excluding previously acceptable ideas. The technique relies on people promoting ideas even less acceptable than the previous "outer fringe" ideas. That makes those old fringe ideas look less extreme, and thereby acceptable. The idea is that priming the public with fringe ideas intended to be and remain unacceptable, will make the real target ideas seem more acceptable by comparison.

The degrees of acceptance of public ideas can be described roughly as:

• Unthinkable
• Radical
• Acceptable
• Sensible
• Popular
• Policy

The Overton Window is a means of visualizing which ideas define that range of acceptance by where they fall in it, and adding new ideas that can push the old ideas towards acceptance merely by making the limits more extreme.

My biggest problem is spending too much time and energy at the unthinkable end of the continuum.

Bernard Avishai on Child Abuse

My recent narratives about health care reform and the economy take a short break here. Today's post by Bernard Avishai is a must-read. It's short and only takes a moment. He's reflecting on the use of children in war. In this case the recent IDF actions in Gaza are the example.Do check the comments thread.

Let me get this straight. We take tens of thousands of 18 and 19-year-olds, young people who are little more than children themselves, and at a time of life when showing the utmost cool is a kind of sexual ante; a time when ideas about the world are largely received wisdoms; when bodies are at their utmost strength but so is the fear of death, which only reinforces the fear of displaying cowardice; when the people from whom wisdoms are received are parents or mentors loved to the utmost; when minds are just intimidated enough about life's scrum to feel utmost gratitude for family and commonwealth--when the desire to prove one's loyalty is at its most intense.

...and that our great friends in the Bush administration are about to leave office, so time is of the utmost importance, too.

Then, after our children have killed and killed for us, we turn around and tell them they did not take the utmost care in trying to save civilian lives; that "this involves taking some risk"--that if they were braver, more willing to risk their own or their buddies' deaths, they would not have violated the "norm" of combat--in effect, that if they were more worthy, they would not be war criminals.

Presumably, some European state prosecuter will now want to take our children to the world court. But I wonder: if the court had a social worker, would she not just be threatening to take them away from their parents?
.

Lest the reader think he's exaggerating, check out this link from Ha'aretz:

The office at the Adiv fabric-printing shop in south Tel Aviv handles a constant stream of customers, many of them soldiers in uniform, who come to order custom clothing featuring their unit's insignia, usually accompanied by a slogan and drawing of their choosing. Elsewhere on the premises, the sketches are turned into plates used for imprinting the ordered items, mainly T-shirts and baseball caps, but also hoodies, fleece jackets and pants. A young Arab man from Jaffa supervises the workers who imprint the words and pictures, and afterward hands over the finished product.

Dead babies, mothers weeping on their children's graves, a gun aimed at a child and bombed-out mosques - these are a few examples of the images Israel Defense Forces soldiers design these days to print on shirts they order to mark the end of training, or of field duty. The slogans accompanying the drawings are not exactly anemic either: A T-shirt for infantry snipers bears the inscription "Better use Durex," next to a picture of a dead Palestinian baby, with his weeping mother and a teddy bear beside him. A sharpshooter's T-shirt from the Givati Brigade's Shaked battalion shows a pregnant Palestinian woman with a bull's-eye superimposed on her belly, with the slogan, in English, "1 shot, 2 kills." A "graduation" shirt for those who have completed another snipers course depicts a Palestinian baby, who grows into a combative boy and then an armed adult, with the inscription, "No matter how it begins, we'll put an end to it."

There are also plenty of shirts with blatant sexual messages. For example, the Lavi battalion produced a shirt featuring a drawing of a soldier next to a young woman with bruises, and the slogan, "Bet you got raped!" A few of the images underscore actions whose existence the army officially denies - such as "confirming the kill" (shooting a bullet into an enemy victim's head from close range, to ensure he is dead), or harming religious sites, or female or child non-combatants.

In many cases, the content is submitted for approval to one of the unit's commanders. The latter, however, do not always have control over what gets printed, because the artwork is a private initiative of soldiers that they never hear about. Drawings or slogans previously banned in certain units have been approved for distribution elsewhere. For example, shirts declaring, "We won't chill 'til we confirm the kill" were banned in the past (the IDF claims that the practice doesn't exist), yet the Haruv battalion printed some last year.

More at the link, if the reader has a stomach for that sort of thing.

Top Tax Tiers History

Congress and the president are missing an obvious chance to adjust income tax rates for everyone.

The flap over excessive bonuses has inspired Congress to take action (for a change) instead of scapegoating the Executive or Judicial branches to do their dirty work. The time is ripe to return to multiple income tax tiers reaching well into the nose-bleed reaches of the super rich.

Take a look at the history of America's progressive income tax back in the day.
This came from the National Taxpayers Union.

Historical Income Tax Rates & Brackets

	Tax Rates 1
	Bottom bracket		Top bracket
Calendar Year	Rate (percent)	Taxable Income Up to	Rate (percent)	Taxable Income over
1913-15	1	20,000	7	500,000
1916	2	20,000	15	2,000,000
1917	2	2,000	67	2,000,000
1918	6	4,000	77	1,000,000
1919-20	4	4,000	73	1,000,000
1921	4	4,000	73	1,000,000
1922	4	4,000	56	200,000
1923	3	4,000	56	200,000
1924	2 1.5	4,000	46	500,000
1925-28	2 1?	4,000	25	100,000
1929	2 4?	4,000	24	100,000
1930-31	2 1?	4,000	25	100,000
1932-33	4	4,000	63	1,000,000
1934-35	3 4	4,000	63	1,000,000
1936-39	3 4	4,000	79	5,000,000
1940	3 4.4	4,000	81.1	5,000,000
1941	3 10	2,000	81	5,000,000
1942-434	3 19	2,000	88	200,000
1944-45	23	2,000	5 94	200,000
1946-47	19	2,000	5 86.45	200,000
1948-49	16.6	4,000	5 82.13	400,000
1950	17.4	4,000	5 91	400,000
1951	20.4	4,000	5 91	400,000
1952-53	22.2	4,000	5 92	400,000
1954-63	20	4,000	5 91	400,000
1964	16	1,000	77	400,000
1965-67	14	1,000	70	200,000
1968	14	1,000	6 75.25	200,000
1969	14	1,000	6 77	200,000
1970	14	1,000	6 71.75	200,000
1971	14	1,000	7 70	200,000
1972-78	814	1,000	7 70	200,000
1979-80	814	2,100	7 70	212,000
1981	8 9 13.825	2,100	7 9 69.125	212,000
1982	8 12	2,100	50	106,000
1983	8 11	2,100	50	106,000
1984	8 11	2,100	50	159,000
1985	8 11	2,180	50	165,480
1986	8 11	2,270	50	171,580
1987	8 11	3,000	38.5	90,000
1988	8 15	29,750	1028	29,750
1989	8 15	30,950	1028	30,950
1990	8 15	32,450	1028	32,450
1991	8 15	34,000	31	82,150
1992	8 15	35,800	31	86,500
1993	8 15	36,900	39.6	250,000
1994	8 15	38,000	39.6	250,000
1995	8 15	39,000	39.6	256,500
1996	8 15	40,100	39.6	263,750
1997	8 15	41,200	39.6	271,050
1998	8 15	42,350	39.6	278,450
1999	8 15	43,050	39.6	283,150
2000	8 15	43,850	39.6	288,350
2001	8 15	45,200	39.1	297,350
2002	8 10	12,000	38.6	307,050
200311	8 10	14,000	35.0	311,950
2004	8 10	14,300	35.0	319,100
2005	8 10	14,600	35.0	326,450
2006	8 10	15,100	35.0	336,550
2007	8 10	15,650	35.0	349,700
2008	8 10	16,050	35.0	357,700

---

1 Taxable income excludes zero bracket amount from 1977 through 1986. Rates shown apply only to married persons filing joint returns beginning in 1948. Does not include either the add on minimum tax on preference items (1970-1982) or the alternative minimum tax (1979-present). Also, does not include the effects of the various tax benefit phase-outs (e.g. the personal exemption phase-out). From 1922 through 1986 and from 1991 forward, lower rates applied to long-term capital gains.

2 After earned-income deduction equal to 25 percent of earned income.

3 After earned-income deduction equal to 10 percent of earned income.

4 Exclusive of Victory Tax.

5 Subject to the following maximum effective rate limitations.

[year and maximum rate (in percent)] 1944-45 –90; 1946-47 –85.5; 1948-49 –77.0; 1950 –87.0; 1951 –87.2; 1952-53 –88.0; 1954-63 –87.0.

6 Includes surcharge of 7.5 percent in 1968, 10 percent in 1969, and 2.6 percent in 1970.

7 Earned income was subject to maximum marginal rates of 60 percent in 1971 and 50 percent from 1972 through 1981.

8 Beginning in 1975, a refundable earned-income credit is allowed for low-income individuals.

9 After tax credit is 1.25 percent against regular tax.

10 The benefit of the first rate bracket is eliminated by an increased rate above certain thresholds. The phase-out range of the benefit of the first rate bracket was as follows: Taxable income between $71,900 and $149,250 in 1988; taxable income between $74,850 and $155,320 in 1989; and taxable income between $78,400 and $162,770 in 1990. The phase-out of the benefit the first rate bracket was repealed for taxable years beginning after December 31, 1990. This added 5 percentage points to the marginal rate for those by the phaseout, producing a 33 percent effective rate.

11 Rates for 2003 are after enactment of the Jobs and Growth Tax Relief Reconciliation Act. Prior to enactment the rates were 10% up to $12,000 and 38.6% on amounts over $311,950.

Sources: Joint Committee on Taxation, "Overview of Present Law and Economic Analysis Relating to Marginal Tax Rates and the President’s Individual Income Tax Rate Proposals" (JCX-6-01), March 6, 2001, and Congressional Research Service, "Statutory Individual Income Tax Rates and Other Elements of the Tax System: 1988 through 2008," (RL34498) May 21, 2008.

Years ago, when my wife and I first married and were too poor to pay attention, I filed my own income tax. Being the nut case that I am for detail, I poured over those government-speak forms for days at a time, looking for ways to save money. Those were the days of multiple deductions and finding them was like looking for eggs on Easter morning. I remember saving all our sales receipts once for an entire year to find out for myself if the various individual state sales tax tables furnished by the IRS were really accurate. I discovered (to mixed disappointment and pleasure) that those tables - at least for Georgia - were actually pretty generous.

Those were the days when medical deductions meant something when you filed for an income tax return. One of our children had to be in a private school for learning disabilities for two years and the tuition was higher than our mortgage payment. We were able to do it because a registered clinical educational psychologist had made the recommendatiion (that was when many public school teachers "didn't believe in" learning disabilities. ADHD was to come later.) so the tuition could be considered a "medical" deduction.

Credit card interst was deductible, along with a host of deductions aimed at helping small businesses.

With the election of Ronald (Government IS the problem) Reagan, the tax codes were "simplified."
Multiple tax tiers were reduced to three.

In return for "flex-plans" allowing insurance premiums to be "pre-tax" individual medical deductions must now exceed a catastrophic percentage of earned income. Anyone with medical expenses over 7.5 percent of AGI is allowed the excess to be deducted, which means you're in damn deep doo-doo for health care at your house.

The big benefit of tax simplification, though, was for those at the top, whose rate was slashed from seventy to fifty percent. As time went by that was reduced another ten percent.

When the tax codes were complicated most wage earners took what was called the "standard deduction." leaving "itemizing" to those with a more complicated picture. Over time this habit has had the effect of dumbing down an already low tax IQ to the point where the "tax service" industry (seasonal, like Christmas tree sales) has become a flourishing enterprise that most ordinary people never realize eats away their hard-earned money worse than pay-day check-cashing outfits.

My wife and I, along with the rest of our super-rich peers, were awash with money after a few years so we didn't worry about anyone else. (Believe that if it makes you feel better.) But we looked with sympathy on our children who went into that dark earnings night unaware that their world was a very different place from the one into which they were born. It was about that time when easy credit became the order of the day.

Deduct credit card interest? Fugedaboudit! As long as you make minimum payments you can use credit cards to the max. Need another one? Go get it.
Don't ask if you can afford something. The question is Can you make the payments?

The reader can see where this is going. Roubini put his finger on it over a year ago (and before) when no one was paying attention. He summarized it well in Forbes last week.

====================

It is time for our elected representatives to see that the last twenty-five years has resulted in a near-fatal harvest of unintended consequences. The progressive income tax was essentially abandoned when three income tax tiers went into effect. Since that time the gap separating rich and poor has opened wider every year.
The time has come to set things right and return to a meaningful update of the Sixteenth Amendment.