The Dish

Kliff heralds the dawn of the Obamacare era:

The next Obamacare fight is going to be about access. After three months of enrollment, January will be the first month when shoppers can see what they purchased. We know that the plans for sale on the marketplace tend to have relatively limited networks, as insurers restricted doctor access to hold down premium prices. New subscribers could find that a doctor they want isn’t in network, and get frustrated. Co-payments may seem alarmingly high — a byproduct of keeping premiums low. While the health-care system probably has the capacity to absorb a few million new insurance subscribers … there is still room for issues about access to specific doctors and the price tag that comes along with trips to the doctor’s office.

Kate Pickert also focuses on limited networks:

A recent study suggests limited provider networks could become more common in the years ahead as the ACA takes hold. A Dec. 13 McKinsey study of 20 U.S. metropolitan areas found that two-thirds of ACA plans analyzed had “narrow” or “ultra narrow” networks, with at least 30 percent of top 20 hospitals excluded for coverage. The medium premium for plans with narrower networks, according to the study, was 26 percent lower than comparable benefit packages with broad networks.

Cohn asked various health care wonks to make predictions about how the ACA will fare this year. Here’s Sean Parnell, author of The Self-Pay Patient, who is among the more pessimistic:

The biggest hurdle will be enrollment, particularly among the young and healthy. Deductibles are high, premium subsidies generally aren’t available except to the poorest, the tax for being uninsured is low, and the young have always been overrepresented among the uninsured. This will continue to be the case in 2014 and beyond.

Late in 2014, insurers will announce premiums for 2015. They will be higher, inflicting a political price on Democrats. Expect more creative interpretations and regulatory flexibility out of the Obama administration in order to smooth over more unintended consequences of the ACA.

There will be more Americans who pay directly for more of their health care. The ACA is projected by the Congressional Budget Office to leave 30 million people uninsured, and tens of millions more will get high-deductible plans through exchanges or their employers. These self-pay patients will demand price transparency and discounts for paying in full at the time of treatment, and innovative entrepreneurs will step up to cater to them while ignoring the traditional third-party payment system.

At the end of 2014, I expect to see many advocates of the ACA look back and conclude that while it’s too early to call the law a failure, the meager results fall far short of what was hoped for.

German-Jewish painter Moritz Daniel Oppenheim’s The Kidnapping of Edgardo Mortara, thought to be lost for over a century, was recently rediscovered and then auctioned by Sotheby’s at their annual Judaica sale. Maya Benton details the controversial episode behind the art:

The painting, lost for more than a century, depicts the notorious case of Edgardo Mortara, a 6-year-old Italian Jewish boy seized by church authorities from his family’s home in Bologna in 1858, based on a rumor that he had been baptized by the family’s illiterate gentile servant girl.

If baptized, the boy would have to be considered a Catholic in the eyes of the church and would no longer be allowed to remain in the home of his Jewish family. Such unauthorized conversions of Jewish children were not uncommon in the papal states. Despite the family’s desperate pleas and protestations, little Edgardo was brought to a monastery in Rome, taken in by the pope, and raised as a Catholic. When he grew up, he became a priest.

The kidnapping of this boy, and his family’s tireless efforts to lobby the Vatican for his return, became a source of international outrage and controversy, galvanizing Jewish leaders, including Moses Montefiore, the Rothschilds, and rabbis throughout America and Europe, who lobbied the pope for Mortara’s return. The case became an international scandal with far-reaching political ramifications.

In an interview, David Kertzer, author of a book on the kidnapping, highlights the impact it had on church-state relations in Europe, especially Italy:

In Italy—well, I wouldn’t say that if not for the Mortara case there would still be papal states today—but the end of the papal states was a matter of convincing the various powers that be that this was an anachronism that could no longer be propped up. There was no more important figure in all of this than Napoleon III, because it was through his intervention, in 1859, that the Kingdom of Italy took shape. He had previously been the pope’s big protector. Indeed, he brought him back to power in 1849, even though personally he had his own anti-clerical past. But I think we have evidence that the Mortara case, which Napoleon III was well aware of, and in which he did indeed intervene, really made him feel that the papal states could no longer survive in the modern world and that he should not be propping them up. He had many other considerations, but the fact is that [the Mortara case] was one of them, and it’s remarkable that this totally unknown 6-year-old Jewish child in Bologna would play this role.

Update from a reader:

The kidnapping became an international incident because of a confluence of events.  Jews were emancipated from European Ghettos during the 1840s and early 1850s at the time Europe was democratizing. Paul Reuter, a Jewish Englishman, invented the news wire in 1851. By the time of the kidnapping, 1858, newspapers, including Jewish papers – were being fed by a wire service offering international news.  Denouncing the kidnapping of Edgardo Mortara became a way for world leaders to emphasize their commitment to democracy and human rights.  Might also be the first example of worldwide Jewry exercising any kind of political influence.

And a noble cause that was.

(Image of The Kidnapping of the Mortara Child by Moritz Daniel Oppenheim, via Sotheby’s)

A reader writes:

Your post on palliative care came at an especially appropriate time, as I witnessed my 80-year-old mother’s quick decline and death just last week. She spent almost three weeks in a local hospital, where it became clear to me and my sister that while she was dying of lung cancer that had metastasized to her liver – but no doctor really wanted to tell her that. Luckily, about three days before she died, she was transferred to Calvary Hospital in the Bronx where they specialize in end-of-life treatment.

What a difference between the two hospitals.

In the first one I had to take the reins in relaying the information to my mother. This was very difficult, since I am not a doctor and did not fully understand everything about her medical situation. But after having her primary care physician tell me on the phone that he wasn’t sure she was accepting of her situation because she became emotional when he brought up that there were no treatments she could tolerate, I knew I had to tell her. It seemed to me that it was the doctor’s discomfort with delivering this type of news and dealing with the patient’s reaction that was hindering us moving forward in a way that respected my mother. She was dying, but she was in no way cognitively impaired or incapable of understanding this.

I hung up the phone with her doctor and took my mother’s hand and laid out the situation as best I could. While it was difficult, she was relieved that someone was telling her what was going on. When I finally insisted that a palliative care person come to speak with her the next day, the woman commented on my mother’s straightforward manner and acceptance of her death. My mother was a no-nonsense woman and her understanding of her situation afforded us the opportunity to have meaningful conversations before her death. This has helped me enormously in my grief.

I imagine if she had been transferred to Calvary earlier in her ordeal we could have had more support in our journey. From the moment she got there, the staff was communicative and respectful of the dying process, unlike her community hospital. I suppose it is our culture that contributes to this inability to deal with death; Americans seem to see death as some type of failing or surrender. But like Peg Nelson describes in your post, it just doesn’t need to be that way. As difficult a time it was, I felt I was honoring my mother by being by her side and helping her face what she was going through. I think it helped us both let go.

Update from a reader:

When my mother was dying of lung cancer some years back, she elected to end her life before the cancer killed her.  A doctor said afterwards that she would have lived another week to a month, with most of that time spent in a coma.  I knew in advance what she planned, read the books, talked to doctors and sat with her while she took the pills that killed her. It was a very peaceful death and, while we all miss her passionately, neither I nor any other member of my family have any regrets about her choice.  We had all been more than willing to care for her but knew her well enough to know that the spiraling loss of control would have made her last days a misery.

What has fascinated me about the aftermath is that having knowledge of this has made me a stop on a peculiar unofficial underground railway.  Friends, friend’s parents, friends of friends of friends (strangers) have called me wanting to know what this experience is like.  I have so little to offer them: compassion, where to look for information, my story.  Not enough.  We are all going to die.  It would help many if we could talk about it.