Jun 21, 2013

Essay on words like "Retarded", "Ni&&er", Christian hypocrisy, and what we should REALLY be talking about in America


So now, conservatives are indignant because liberal HBO comic Bill Maher called Sarah Palin's retarded son, Trig,  "Retarded"  (He's young and tragically, has Down's Syndrome, as a lot of Americans do.    



Southern Cook personality Paula Deen gets fired from the Food Network for using the N word.


   Lets kick this around for awhile.



I think the word 'retarded' is much different than the N word. It is admittedly used as an epithet by teenagers towards each other. But not on the same level. Some people ARE retarded. Today's PC society likes to find more gentle words. "Developmentally Disabled" is one of those. The feds used "SMH" and "SMR" (Severely mentally handicapped), (Severely Mentally Retarded) back in about 1980, when Congress passed 94-142, The first nationwide Education for the Handicapped Children law that mandated special education for all children needing services. Very EXPENSIVE SERVICES.

Services Republicans want to CUT to the bone...setting America back 40 years! Even so, educators are always looking for softer gentler words and phrases to label people after they wear certain labels out.

Remember when schools couldn't be called 'schools"? The trendy educationeeze phrase was "Attendence Centers." Just crap coined by people with EdD,s and PhD's who write research papers.

Now of course, we have school shootings and metal detectors. But the short-bus and schoolbus bullying and namecalling remains, doens't it Paula Deen?

And the point that reminds Christians of their hypocrisy. When it comes to charity, and helping the 'least of my brothers" with foodstamps when they work Walmart wages, "What would Jesus do?"....instead of building fundamentalist megachurches in the suburbs?

I'm kinda waiting for the churches, deadset against abortion and birth control, will pass their Sunday plates to pay the medical bills for these chronically unhealthy children who cannot take care of themselves from birth to death. They wouldn't let comotose Terri Schievo's husband cut her food supply and let her die with dignity.... but I didn't notice any Christians offering to pick up the tab for her and many thousands like her, hidden away in nursing homes and 'ventilator farms' for motorcycle accident victims, birth defected children now adults, and all the other stuff the media never tells us about.

What should we be indignant about? Who should decide these policy decisions? Government? Tea Partiers, libertarians? Liberals who apply Christian principles of charity to the infirm, or conservatives who just look at the costs so they can put their riches in the stockmarket to make more money? 

Sadly, religious leadership in America has failed their flock on these difficult matters. How can talk radio not address these difficult matters?

Again, what would Jesus call "Doing the Right thing?" Have you noticed this new Catholic Pope is raising these difficult questions to his large flock. And creating quite a bit of controversy, especially among the conservative protestants, who the Catholic Church continues to patiently wait to return to the Universal Church!

(This of course is NOT the same Catholic Church of the 1940s who excommunicated my mother for marrying my protestant father. But we've learned not to say the N word since then, too, right? My dad died, by the way, no longer using the N word....for those N's were wiping his feeble ass in the nursing home where he died.) 

A lot of attitudes have changed during my lifetime in the last half of the 20th century. But we still have a ways to go on all sorts of topics... money, charity, war, respect for each other, 
descrimination, judgmentalness, hypocrisy. And spiritual awareness of how we fit in a universe where the Hubble Telescope shows us millions of suns and planets in the far distance.

Wait til the aliens show up. We won't know whether to shit or go blind!

Jun 20, 2013

Guest Editorial... why small government isn''t a good thing. Not THESE days!

The Knowledge Movement · 38,975 like this
3 minutes ago · 
  • LESS GOVERNMENT EQUALS MORE FREEDOM IS RIGHTING CRAZINESS

    Getting government out of your life doesn't make you free, it exposes you fully to the beast that would [really] steal your freedom -- Corporate America.

    Some people have this romanticized fantasy that less government automatically equates to more freedom but that's up there with flying unicorns, leprechauns and gold at the end of the rainbow.
    Maybe if we were talking [real] Communism or Marxism, "too much government" might apply but to give this term to the economic system in America we are currently under, which is by definition Keynesian economics; a form of Capitalism, would be ignorant at best and laughably ridiculous at worst.

    The funny thing about this fantasy is it's not really a fantasy nor an untested theory -- it's already been done. So technically it could be called a failed experiment that we discarded that some want to dig out of the trash and try again, when all we really need to do is look at the test results from the original trials, which would tell us why we trashed it in the first place.

    For starters, uninhibited Capitalism, financial markets without government interference in the 1920s', did not form itself into the self regulating, self balancing, economic engine Rightwingers today seem to think no regulations will bring. The result of "no government" was the largest financial collapse in American history, commonly called the Great Depression.

    Government serves the people and must answer to the people. If they do not do a good job at serving the people the people will replace them. However, there's a completely different construct for Corporations. They are not beholden to "the people" but only their own shareholders. While government has a responsibility to protect its citizens, corporations have no such obligations. They have one objective only and that's to make as big a profit at as little expense as possible. This means if it's profitable for them to sell houses with led in the paint, knowing full well it will cause mental retardation in some children, they will and have done it. But it's the government that forced them to stop.

    If it were profitable for them to push something as healthy, or at a minimum non-hazardous, when they knew it caused cancer, they would and have done it (Tobacco Industry). But again, government is what stopped them.

    If it were profitable to have their employees work in life threatening conditions, or without lunch breaks they would, and have done that. But government allowing workers the right to organize and bargain stopped that.

    Capitalism is like a huge, magnificent, ravenous, beast. It does not set out to maim or kill but will not hesitate to do so if such a results will increase its profit margin. The only moral in its code is that it meet its bottom line. Its appetite is never vanquished and if not held in check it will, and has, in 1929 and 2007, brought down the very house in which it resides. The only thing big enough and powerful enough to leash this great beast, to force it to conform to ethics, and to stand between it and the citizens being trampled beneath its feet is the government.

    Government controls corporate abuse through legislation and the people control the government through the election process -- that's Capitalism. Those espoused to taking government out of the equation are either corporate hacks in government, like a Rand Paul for instance, who is bank rolled by numerous corporations or supporters of these corporate hacks, generally the Rightwing electorate, deluded by the fictitious version of freedom they've been sold and clueless to what it would take to truly attain real freedom.

    TAG

Jun 16, 2013

Syria is getting dangerous. New COLD WAR with RUSSIA. Putin Pouts!

Is the cold war back with Russia?

President Barack Obama and his Russian counterpart, Vladimir Putin, put their escalating differences over Syria on display even as they agreed to urge both sides in the civil war there to the negotiating table.


“Of course, our opinions do not coincide” on Syria, Putin said when the two went before the television cameras after meeting on the sidelines of an international summit in Northern Ireland. “We do have differing perspectives,” Obama said, while adding that “we share an interest in reducing the violence.”

U.S. President Barack Obama, left, holds a bilateral meeting with Russian President Vladimir Putin during the G8 summit at the Lough Erne resort in Northern Ireland, on June 17, 2013. Photographer: Jewel Samad/AFP via Getty Images

Some Western leaders publicly rebuked Putin for his support of Syrian President Bashar al-Assad as the Group of Eight summit of industrial nations began.


Obama and Putin focused on areas of agreement in remarks after the talks, their first one-on-one meeting in a year, both offering hopes that the Iranian elections would open way for progress in negotiations to that country’s nuclear program and noting common efforts on counterterrorism. Obama began his comments by thanking Russia for assistance with the investigation into the Boston marathon bombings.

More on this from Bloomberg

Is this a precursor to WWIII?   US going head to head in another MIDEAST SKIRMISH


Washington’s decision to arm Syria’s Sunni Muslim rebels has plunged America into the great Sunni-Shia conflict of the Islamic Middle East, entering a struggle that now dwarfs the Arab revolutions which overthrew dictatorships across the region.

For the first time, all of America’s ‘friends’ in the region are Sunni Muslims and all of its enemies are Shiites. Breaking all President Barack Obama’s rules of disengagement, the US is now fully engaged on the side of armed groups which include the most extreme Sunni Islamist movements in the Middle East.

The Independent on Sunday has learned that a military decision has been taken in Iran – even before last week’s presidential election – to send a first contingent of 4,000 Iranian Revolutionary Guards to Syria to support President Bashar al-Assad’s forces against the largely Sunni rebellion that has cost almost 100,000 lives in just over two years.  Iran is now fully committed to preserving Assad’s regime, according to pro-Iranian sources which have been deeply involved in the Islamic Republic’s security, even to the extent of proposing to open up a new ‘Syrian’ front on the Golan Heights against Israel.

In years to come, historians will ask how America – after its defeat in Iraq and its humiliating withdrawal from Afghanistan scheduled for  2014 – could have so blithely aligned itself with one side in a titanic Islamic struggle stretching back to the seventh century death of the Prophet Mohamed.

Read the rest...from "The Independent".


Remember... Vietnam started with "US Advisors"

Jun 6, 2013

Big Brother BUSH was watching the other side of your keyboard! And Phone Records! Bigger than you thought.



Documents: U.S. mining data from 9 leading Internet firms; companies deny knowledge

By Barton Gellman and Laura Poitras, Thursday, June 6, 4:43 PM

The National Security Agency and the FBI are tapping directly into the central servers of nine leading U.S. Internet companies, extracting audio and video chats, photographs, e-mails, documents, and connection logs that enable analysts to track foreign targets, according to a top-secret document obtained by The Washington Post.

The program, code-named PRISM, has not been made public until now. It may be the first of its kind. The NSA prides itself on stealing secrets and breaking codes, and it is accustomed to corporate partnerships that help it divert data traffic or sidestep barriers. But there has never been a Google or Facebook before, and it is unlikely that there are richer troves of valuable intelligence than the ones in Silicon Valley.

Equally unusual is the way the NSA extracts what it wants, according to the document: “Collection directly from the servers of these U.S. Service Providers: Microsoft, Yahoo, Google, Facebook, PalTalk, AOL, Skype, YouTube, Apple.”

PRISM was launched from the ashes of President George W. Bush’s secret program of warrantless domestic surveillance in 2007, after news media disclosures, lawsuits and the Foreign Intelligence Surveillance Court forced the president to look for new authority.

Congress obliged with the Protect America Act in 2007 and the FISA Amendments Act of 2008, which immunized private companies that cooperated voluntarily with U.S. intelligence collection. PRISM recruited its first partner, Microsoft, and began six years of rapidly growing data collection beneath the surface of a roiling national debate on surveillance and privacy. Late last year, when critics in Congress sought changes in the FISA Amendments Act, the only lawmakers who knew about PRISM were bound by oaths of office to hold their tongues.

The court-approved program is focused on foreign communications traffic, which often flows through U.S. servers even when sent from one overseas location to another. Between 2004 and 2007, Bush administration lawyers persuaded federal FISA judges to issue surveillance orders in a fundamentally new form. Until then the government had to show probable cause that a particular “target” and “facility” were both connected to terrorism or espionage.

In four new orders, which remain classified, the court defined massive data sets as “facilities” and agreed to certify periodically that the government had reasonable procedures in place to minimize collection of “U.S. persons” data without a warrant.

In a statement issue late Thursday, Director of National Intelligence James R. Clapper said “information collected under this program is among the most important and valuable foreign intelligence information we collect, and is used to protect our nation from a wide variety of threats. The unauthorized disclosure of information about this important and entirely legal program is reprehensible and risks important protections for the security of Americans.”

Clapper added that there were numerous inaccuracies in reports about PRISM by The Post and the Guardian newspaper, but he did not specify any.

Jameel Jaffer, deputy legal director of the American Civil Liberties Union, said: “I would just push back on the idea that the court has signed off on it, so why worry? This is a court that meets in secret, allows only the government to appear before it, and publishes almost none of its opinions. It has never been an effective check on government.”

British Liberal newspaper broke this story, this week.
Several companies contacted by The Post said they had no knowledge of the program, did not allow direct government access to their servers and asserted that they responded only to targeted requests for information.

“We do not provide any government organization with direct access to Facebook servers,” said Joe Sullivan, chief security officer for Facebook. “When Facebook is asked for data or information about specific individuals, we carefully scrutinize any such request for compliance with all applicable laws, and provide information only to the extent required by law.”

“We have never heard of PRISM,” said Steve Dowling, a spokesman for Apple. “We do not provide any government agency with direct access to our servers, and any government agency requesting customer data must get a court order.”

It is possible that the conflict between the PRISM slides and the company spokesmen is the result of imprecision on the part of the NSA author. In another classified report obtained by The Post, the arrangement is described as allowing “collection managers [to send] content tasking instructions directly to equipment installed at company-controlled locations,” rather than directly to company servers.

National Security Ageny Campus - Time Magazine
Government officials and the document itself made clear that the NSA regarded the identities of its private partners as PRISM’s most sensitive secret, fearing that the companies would withdraw from the program if exposed. “98 percent of PRISM production is based on Yahoo, Google and Microsoft; we need to make sure we don’t harm these sources,” the briefing’s author wrote in his speaker’s notes.

An internal presentation of 41 briefing slides on PRISM, dated April 2013 and intended for senior analysts in the NSA’s Signals Intelligence Directorate, described the new tool as the most prolific contributor to the President’s Daily Brief, which cited PRISM data in 1,477 items last year. According to the slides and other supporting materials obtained by The Post, “NSA reporting increasingly relies on PRISM” as its leading source of raw material, accounting for nearly 1 in 7 intelligence reports.

That is a remarkable figure in an agency that measures annual intake in the trillions of communications. It is all the more striking because the NSA, whose lawful mission is foreign intelligence, is reaching deep inside the machinery of American companies that host hundreds of millions of American-held accounts on American soil.

The technology companies, whose cooperation is essential to PRISM operations, include most of the dominant global players of Silicon Valley, according to the document. They are listed on a roster that bears their logos in order of entry into the program: “Microsoft, Yahoo, Google, Facebook, PalTalk, AOL, Skype, YouTube, Apple.” PalTalk, although much smaller, has hosted traffic of substantial intelligence interest during the Arab Spring and in the ongoing Syrian civil war.

Dropbox, the cloud storage and synchronization service, is described as “coming soon.”

Sens. Ron Wyden (D-Ore.) and Mark Udall (D-Colo.), who had classified knowledge of the program as members of the Senate Intelligence Committee, were unable to speak of it when they warned in a Dec. 27, 2012, floor debate that the FISA Amendments Act had what both of them called a “back-door search loophole” for the content of innocent Americans who were swept up in a search for someone else.

“As it is written, there is nothing to prohibit the intelligence community from searching through a pile of communications, which may have been incidentally or accidentally been collected without a warrant, to deliberately search for the phone calls or e-mails of specific Americans,” Udall said.

Wyden repeatedly asked the NSA to estimate the number of Americans whose communications had been incidentally collected, and the agency’s director, Lt. Gen. Keith B. Alexander, insisted there was no way to find out. Eventually Inspector General I. Charles McCullough III wrote Wyden a letter stating that it would violate the privacy of Americans in NSA data banks to try to estimate their number.

Roots in the ’70s

PRISM is an heir, in one sense, to a history of intelligence alliances with as many as 100 trusted U.S. companies since the 1970s. The NSA calls these Special Source Operations, and PRISM falls under that rubric.

The Silicon Valley operation works alongside a parallel program, code-named BLARNEY, that gathers up “metadata” — technical information about communications traffic and network devices — as it streams past choke points along the backbone of the Internet. BLARNEY’s top-secret program summary, set down in the slides alongside a cartoon insignia of a shamrock and a leprechaun hat, describes it as “an ongoing collection program that leverages IC [intelligence community] and commercial partnerships to gain access and exploit foreign intelligence obtained from global networks.”

But the PRISM program appears to more nearly resemble the most controversial of the warrantless surveillance orders issued by President George W. Bush after the al-Qaeda attacks of Sept. 11, 2001. Its history, in which President Obama presided over exponential growth in a program that candidate Obama criticized, shows how fundamentally surveillance law and practice have shifted away from individual suspicion in favor of systematic, mass collection techniques.

The Obama administration points to ongoing safeguards in the form of “extensive procedures, specifically approved by the court, to ensure that only non-U.S. persons outside the U.S. are targeted, and that minimize the acquisition, retention and dissemination of incidentally acquired information about U.S. persons.”

And it is true that the PRISM program is not a dragnet, exactly. From inside a company’s data stream the NSA is capable of pulling out anything it likes, but under current rules the agency does not try to collect it all.

Analysts who use the system from a Web portal at Fort Meade, Md., key in “selectors,” or search terms, that are designed to produce at least 51 percent confidence in a target’s “foreignness.” That is not a very stringent test. Training materials obtained by The Post instruct new analysts to make quarterly reports of any accidental collection of U.S. content, but add that “it’s nothing to worry about.”

Even when the system works just as advertised, with no American singled out for targeting, the NSA routinely collects a great deal of American content. That is described as “incidental,” and it is inherent in contact chaining, one of the basic tools of the trade. To collect on a suspected spy or foreign terrorist means, at minimum, that everyone in the suspect’s inbox or outbox is swept in. Intelligence analysts are typically taught to chain through contacts two “hops” out from their target, which increases “incidental collection” exponentially. The same math explains the aphorism, from the John Guare play, that no one is more than “six degrees of separation” from any other person.

A ‘directive’

In exchange for immunity from lawsuits, companies such as Yahoo and AOL are obliged to accept a “directive” from the attorney general and the director of national intelligence to open their servers to the FBI’s Data Intercept Technology Unit, which handles liaison to U.S. companies from the NSA. In 2008, Congress gave the Justice Department authority for a secret order from the Foreign Surveillance Intelligence Court to compel a reluctant company “to comply.”

In practice, there is room for a company to maneuver, delay or resist. When a clandestine intelligence program meets a highly regulated industry, said a lawyer with experience in bridging the gaps, neither side wants to risk a public fight. The engineering problems are so immense, in systems of such complexity and frequent change, that the FBI and NSA would be hard pressed to build in back doors without active help from each company.

Apple demonstrated that resistance is possible when it held out for more than five years, for reasons unknown, after Microsoft became PRISM’s first corporate partner in May 2007. Twitter, which has cultivated a reputation for aggressive defense of its users’ privacy, is still conspicuous by its absence from the list of “private sector partners.”

Google, like the other companies, denied that it permitted direct government access to its servers.

“Google cares deeply about the security of our users’ data,” a company spokesman said. “We disclose user data to government in accordance with the law, and we review all such requests carefully. From time to time, people allege that we have created a government ‘back door’ into our systems, but Google does not have a ‘back door’ for the government to access private user data.”

Microsoft also provided a statement: “We provide customer data only when we receive a legally binding order or subpoena to do so, and never on a voluntary basis. In addition we only ever comply with orders for requests about specific accounts or identifiers. If the government has a broader voluntary national security program to gather customer data we don’t participate in it.”

Yahoo also issued a denial.

“Yahoo! takes users’ privacy very seriously,” the company said in a statement. “We do not provide the government with direct access to our servers, systems, or network.”

Like market researchers, but with far more privileged access, collection managers in the NSA’s Special Source Operations group, which oversees the PRISM program, are drawn to the wealth of information about their subjects in online accounts. For much the same reason, civil libertarians and some ordinary users may be troubled by the menu available to analysts who hold the required clearances to “task” the PRISM system.

There has been “continued exponential growth in tasking to Facebook and Skype,” according to the PRISM slides. With a few clicks and an affirmation that the subject is believed to be engaged in terrorism, espionage or nuclear proliferation, an analyst obtains full access to Facebook’s “extensive search and surveillance capabilities against the variety of online social networking services.”

According to a separate “User’s Guide for PRISM Skype Collection,” that service can be monitored for audio when one end of the call is a conventional telephone and for any combination of “audio, video, chat, and file transfers” when Skype users connect by computer alone. Google’s offerings include Gmail, voice and video chat, Google Drive files, photo libraries, and live surveillance of search terms.

Firsthand experience with these systems, and horror at their capabilities, is what drove a career intelligence officer to provide PowerPoint slides about PRISM and supporting materials to The Washington Post in order to expose what he believes to be a gross intrusion on privacy. “They quite literally can watch your ideas form as you type,” the officer said.


Poitras is a documentary filmmaker and MacArthur Fellow. Julie Tate, Robert O’Harrow Jr., Cecilia Kang and Ellen Nakashima contributed to this report.

Graphic: NSA slides explain the PRISM data-collection program Special Report: Top Secret America


© The Washington Post Company

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Time Magazine's Report today...

And surprise surprise... newspaper 2006, the Bush Administration.    Where was the right's outrage THEN?

https://fbcdn-sphotos-h-a.akamaihd.net/hphotos-ak-prn1/945171_10151628593237593_2030952828_n.jpg

Jun 4, 2013

You're paying THOUSANDS OF YOUR DOLLARS! DO YOU EVEN CARE, or just ACCEPT IT?Why is Congress trashing OBAMACARE but yet ignoring the REAL costs We're paying by Greedy hospitals?


Why are we being ripped off?   Could it be that hospitals and doctors don't actually TELL us what they're charging, don't actually even KNOW?   And your insurance companies quietly pay the bills with a nice negotiated discount, charge your boss and you higher premiums, and THEN... the hospital gouges you for your co-pay amount at a higher rate? 

Think this is Obama's fault?  Oh no.  This is about MONEY for HEALTH CARE, not at all about presidents!

If the REPUBLICANS weren't so interested in making Obama FAIL, they would have helped make OBAMACARE actually WORK!    Address the Healthcare RIPOFF by the industry itself... and the Congressmen looking the other way!!

   But NO....they wanted Obama's ass...even if it costs you BILLIONS, (and you personally, THOUSANDS!)      Now they're playing "See, we told you your premiums would go UP"!     But they didn't turn a finger to stop the health care GOUGING on us all.    This is how badly they want to take over the white house in 2016!   They just don't care WHAT it costs you...and hope it'll cost you a LOT so you'll just vote for them in 2014 for the House and 2016 for the House again and also for the Presidency to an unchosen candidate!   

Patriotic?  I don't think so!   Do you really?   VOTE THEM OUT!   They QUIETLY looked out for THEMSELVES, not YOU!






--------------------

Take the case of just COLOSTOMIES... many of us get them cuz the doctor says we should HAVE ONE, once in a while....

MERRICK, N.Y. — Deirdre Yapalater’s recent colonoscopy at a surgical center near her home here on Long Island went smoothly: she was whisked from pre-op to an operating room where a gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385.

That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.

“Could that be right?” said Ms. Yapalater, stunned by charges on the statement on her dining room table. Although her insurer covered the procedure and she paid nothing, her health care costs still bite: Her premium payments jumped 10 percent last year, and rising co-payments and deductibles are straining the finances of her middle-class family, with its mission-style house in the suburbs and two S.U.V.’s parked outside. “You keep thinking it’s free,” she said. “We call it free, but of course it’s not.”

In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.
Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.

Americans pay, on average, about four times as much for a hip replacement as patients in Switzerland or France and more than three times as much for a Caesarean section as those in New Zealand or Britain. The average price for Nasonex, a common nasal spray for allergies, is $108 in the United States compared with $21 in Spain. The costs of hospital stays here are about triple those in other developed countries, even though they last no longer, according to a recent report by the Commonwealth Fund, a foundation that studies health policy.


While the United States medical system is famous for drugs costing hundreds of thousands of dollars and heroic care at the end of life, it turns out that a more significant factor in the nation’s $2.7 trillion annual health care bill may not be the use of extraordinary services, but the high price tag of ordinary ones. “The U.S. just pays providers of health care much more for everything,” said Tom Sackville, chief executive of the health plans federation and a former British health minister.

Colonoscopies offer a compelling case study. They are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs.

Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.

In coming months, The New York Times will look at common procedures, drugs and medical encounters to examine how the economic incentives underlying the fragmented health care market in the United States have driven up costs, putting deep economic strains on consumers and the country.
Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.

The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.” And it identified federal spending on government health programs as a primary cause of long-term budget deficits.

While the rise in health care spending in the United States has slowed in the past four years — to about 4 percent annually from about 8 percent — it is still expected to rise faster than the gross domestic product. Aging baby boomers and tens of millions of patients newly insured under the Affordable Care Act are likely to add to the burden.


With health insurance premiums eating up ever more of her flat paycheck, Ms. Yapalater, a customer relations specialist for a small Long Island company, recently decided to forgo physical therapy for an injury sustained during Hurricane Sandy because of high out-of-pocket expenses. She refused a dermatology medication prescribed for her daughter when the pharmacist said the co-payment was $130. “I said, ‘That’s impossible, I have insurance,’ ” Ms. Yapalater recalled. “I called the dermatologist and asked for something cheaper, even if it’s not as good.”

The more than $35,000 annually that Ms. Yapalater and her employer collectively pay in premiums — her share is $15,000 — for her family’s Oxford Freedom Plan would be more than sufficient to cover their medical needs in most other countries. She and her husband, Jeff, 63, a sales and marketing consultant, have three children in their 20s with good jobs. Everyone in the family exercises, and none has had a serious illness.

Like the Yapalaters, many other Americans have habits or traits that arguably could put the nation at the low end of the medical cost spectrum. Patients in the United States make fewer doctors’ visits and have fewer hospital stays than citizens of many other developed countries, according to the Commonwealth Fund report. People in Japan get more CT scans. People in Germany, Switzerland and Britain have more frequent hip replacements. The American population is younger and has fewer smokers than those in most other developed countries. Pushing costs in the other direction, though, is that the United States has relatively high rates of obesity and limited access to routine care for the poor.

A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.
“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. ”But it is a very weird market, riddled with market failures.”

Consider this:
Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending.

Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. “It’s impossible for me to think about cost,” he said. “If you go to the supermarket and there are no prices, how can you make intelligent decisions?”
Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.
“It all comes down to market share, and very rarely is anyone looking out for the patient,” said Dr. Jeffrey Rice, the chief executive of Healthcare Blue Book, which tracks commercial insurance payments. “People think it’s like other purchases: that if you pay more you get a better car. But in medicine, it’s not like that.”

A Market Is Born

As the cases of bottled water and energy drinks stacked in the corner of the Yapalaters’ dining room attest, the family is cost conscious — especially since a photography business long owned by the family succumbed eight years ago in the shift to digital imaging. They moved out of Manhattan. They rent out their summer home on Fire Island. They have put off restoring the wallpaper in their dining room.

And yet, Ms. Yapalater recalled, she did not ask her doctors about the cost of her colonoscopy because it was covered by insurance and because “if a doctor says you need it, you don’t ask.” In many other countries, price lists of common procedures are publicly available in every clinic and office. Here, it can be nearly impossible to find out.