June 2017 – Pat the Expat

Where do they get their groceries?

When my dear wife and I travel, we often play a game where we look at some small, out of the way hamlet and ask “where do they get their groceries?” Sometimes the answer is just around a corner, where we pass a general store, but often there is no obvious answer.

Here in Mexpat land, there are several obvious answers. First off, we have mega-chains like Costco and Sam’s in Guadalajara. We also have traditional supermarkets, including a Walmart here in Ajijic and a Soriana next door in Chapala, and another called Mega near Guadalajara. All of this retail infrastructure would be very familiar to any visitor from NOB. While prices at these retailers are good, they are not the budget-friendly option in Mexico. Places like SuperLake stock the usual local foodstuffs but also exotic imports–at a mark-up–for the expat crowd.

Next there are the small specialty stores: the butchers, the bakers, the tortilla-makers. These are generally small shops run by families and marketing a very specific product. Again, not unlike the American market 50 years ago, but here the small retailers were never run out of business like they were so often in the States. Today in the States, these small shops are usually high-end or boutique retailers, while in Mexico they are budget-friendly providers.

One variation on the specialty shop is also one of the more unique retail operations in Mexico: the “guy-with-the-truck.” We can track the Dairy Guy, have heard rumors about the Beef Guy and the Fish Guy, and we absolutely rely on the Coffee Guy. These entrepreneurs load up their specialty wares and stop at specific locations on specific days, where you can walk up to their trucks and purchase your food. Somewhat like the food truck movement NOB, but for the raw ingredients, not finished meals.

Another retail form are abarrotes, literally grocers. These are mini-general stores, usually run out of the first floor of the home or even a room in the family’s casa, and they stock the usual suspects: things in constant demand by locals at very low prices. They are ubiquitous.

Finally, the most important retail operation in any village or town is the tianguis, or market. Usually set for a given day and deconflicted with neighboring towns (so if you miss your tianguis, you can take the bus down the road and visit the next village’s tomorrow), tianguis are a melange of fresh fruits and vegetables, snacks, toys, electronica, carry-out meals, pets, you name it. The tianguis is as much a social event as a shopping trip.

The tianguis is a cross between a farmer’s market and a county fair. It sprouts up once a week, transforming the street in the process. Wonder how the stalls get the power to run their cooking or entertainment devices? If you enlarge my photos, you’ll see an multiplug stuck into an extension cord leading up the stone wall. Somebody climbs a pole and hacks into the overhead electrical wiring!

How about some just finished art with your fresh coconut water?

Once around the lake

We took a guided tour around our lake with Charter Club Tours, starting from Ajijic and going clockwise. I’ll let the pictures do the talking:

Map of Lake Chapala, Jalisco

Chapala’s historic train station, which means no mas trains

Many Mexican towns have an ancient name (Itzican) with a Christian name attached (San Pedro).

The eagle/snake/cactus melange, symbol of Mexico, and

Stained glass ceiling in Ocotlan city building

the miraculous sighting of the Christ crucified on the next day, which

led Ocotlan to build a new church. Note the the hedge spelling PRODIGO or miracle

Jamay likes Pope Pius IX, so they put this monument to him in their square

Most Mexican towns have a square that remains the center of town life. The squares were clean and full of people going about their business.

To get to the birrieria, of course (don’t ask)

Lunch with our guide/driver, Hernan, and Chris and Fran, tour friends. Judy had birria for lunch

Murals of the tianguis in La Morena house,

in La Barca. The bladders are full of Pulque, a fermented drink similar to Mezcal or Tequila

Lakefront in Petatan: thousands of Pelicans overwinter here, but now those snowbirds have flown

View of home, from across the lake. Our place is just below the small hill with a barren spot, lower right quadrant. Note how close the mountains are to the lake.

That’s all folks; hope you enjoyed!

The Blessed Rain

Here in the mile-high-desert-plain-beside-the-lake, we have a dry season (November-May) and a rainy season (June-October). While we are in the tropics, we don’t have a proper monsoon, just regular weather patterns with fronts that bring consistent rains. Many rain storms happen in the early evening, as the storms blow north across the lake and attempt to scale the mountains which hug the north shore communities. For you weather geeks, it is called orographic precipitation, and it happens often enough here to be local legend.

So for expats around Lake Chapala, May and the dry weeks in June are the most uncomfortable. It is desert-dry, and the sun can easily cook up 90 degrees. Many year-round expats plan their “vacations” or visits back NOB during this time. We had visited lakeside during this period, but coming from DC and only being here for a week or two, the dry heat seemed a relief in comparison. This time, we were here for the whole hot, dry mess. As Don Henley put it, “stuck here in limbo, tryin’ to say sane, ‘tween the end of the summer, and the coming of the blessed rain.”

We have neither air conditioning nor heating; they just don’t build many houses here with either. We arrived in February and brought along a bed-size heating pad, but we never used it: not cold enough. The hot/dry time got to us, mainly because it was so relentless. You could not escape the sun/heat during the day, although it did cool down at night. We eventually succumbed and bought a swamp cooler, a fascinating device which looks like a portable air conditioner but is just a water tank, a pump, and a fan. The pump pushes the water from the tank in front of the fan, where it evaporates, cooling the air which blows out of the unit. The air is not cold, just cooler. The unit is effectively a “humidifier” since it works exactly opposite those de-humidifiers some of you may have NOB. Swamp coolers have long been used in very dry areas; where the humidity is already high, they do not work.

Over the course of the dry season, the mountains get progressively browner, dust builds up, and it gets hotter… “yeah, but it’s a dry heat.” The lake level begins to fall as more of it evaporates in the very dry conditions. Sometime in May, you start to hear the shrill cry of the rainbirds, which are not birds, and have nothing to do with the rain. Rainbirds are incredibly loud insects (cicadas, I believe) which emerge at the end of the dry season and set out making a racket. They are loudest initially up on the mountains, but by the beginning of June you can hear them singing nearly everywhere during the day.

Adding to the sun, arid heat, ebbing shoreline, and the rainbirds, May is when local farmers start burning their fields to prepare the soil before planting once the rains hit. I use the terms “farmers” and “fields” advisedly, because they cover a gamut of situations from large, industrial berry fruit operations to locals planting in their backyards to ejidos planting corn and pasturing cattle on the mountainsides.You can smell a faint hint of smoke anywhere, and sometimes see the fires burning in the mountains at night. Lucky us, this year was also a record-setter for fires in the nearby Jalisco forests.

Look closely, there is a mountain missing in the distance

Just about the time you start to think that 10 and 1/2 months of perfect weather are not good enough to make up for all this, one afternoon you spy thick, ominous clouds coming over the far side of the lake. They seem to rush across in the afternoon, and then stall at the foot of the near-side mountains, like tired runners with a final hill to climb before the finish line. As they slowly climb they get darker, and begin to rumble and crackle. The deluge begins, all is forgiven. Happy Rainy Season!

Some Thoughts on Health Care

Everyone had a good laugh when President Trump suddenly announced that “no one knew how difficult health care was going to be” but it may be (unintentionally) the most truthful thing he ever said. Obamacare was a partial solution that reduced the rolls of the uninsured by raising the numbers in Medicaid, creating state exchanges for some, and requiring health insurance for young, healthy individuals who did not want it (or “taxing” them, per the Supreme Court). The Republican’s AHCA is so full of holes in barely merits consideration.

The problems of Obamacare are obvious. Greatly increasing the number of people on Medicaid without increasing the number of doctors accepting Medicaid reimbursement meant theoretical health care, if at all, for many of the poor and sick. State exchanges turned out to be successful as long as federal reinsurance for providers and federal subsidies for consumers were guaranteed to continue to increase indefinitely. And counting young, healthy people as “insured” with a product they never wanted is a unique approach to accounting. So if all this was pretty predictable, why did the Obama administration try it? Why didn’t they go for a single payer option? Federalize healthcare? And why are the Republicans so unprepared to replace Obamacare, if they knew it wouldn’t work and had seven years to prepare to replace it?

“Facts are stubborn things,” as John Adams once said, and here are several facts about health care in America that must be faced directly if we are ever to make any real progress.

Insurance is not health care. Offering insurance where no health care providers participate is a sick joke. This is the challenge of enlarging Medicaid any further. It was also the challenge undermining the state exchanges, where health care providers are leaving because they can’t make enough profit to justify being in the market. Unless you are willing to “draft” our existing health infrastructure into federal service, you have to address the profit motive, and health care supply and demand. Doctors and hospitals (even non-profits) are a limited resource. Those who still desire to federalize health care need look no further than the VA for a probable outcome, and the TSA for a worst case scenario.
More Americans get their health care through their work…still. Many policy types hate this fact, and it does cause the complication that those who lose their jobs also lose their health care. But it is a stubborn fact that can not be ignored, and should not be changed just because it is inconvenient to the good ideas of policy makers. Health care has been, and remains, one of the various benefits employers use to attract employees.
Appeals for empathy are part of the problem, not part of the solution. Attempts to portray any new idea or policy as “killing grandma” simply ensure nothing will change. Hard cases like the “Jimmy Kimmel” challenge are a case in point. To remind, Kimmel’s newborn son had a congenital heart condition who required emergency surgery to survive. He cited this case as an example of the horror awaiting the poor who don’t have their children born at expensive, private hospitals. Perhaps he is unaware of the Emergency Medical Treatment and Labor Act (EMTLA) of 1986, which requires public hospitals to provide life-saving emergency medical care without payment/insurance. So his hard case is already covered in law. Such appeals only provide more smoke and heat, but rarely shed any light.
Americans are unwilling to adopt healthy lifestyles, and unwilling to accept anything that smacks of health care rationing. This is my most debatable “fact,” but one I think most would admit. Too many American’s approach to health seems to be “leave me alone to eat and drink as I like and do no exercise, but be there with a wonder drug when something goes wrong. If things get worse, continue trying to make me better or just keep me alive no matter what.” In some respects, this is like the economic concept of inelastic demand, in that the health consumer wants the best regardless of cost. Unfortunately, this results in poor health outcomes, elevated costs, and a miracle pill mentality.
Insurance is a tool that covers catastrophe, period. The concept is you get insurance to cover unforeseen costs which would otherwise be unpayable. If you try to use insurance for more than that, you are misusing the tool, which will backfire. Car insurance covers your catastrophic loss, or repairs if your car is damaged and unusable. It does not cover fuel, or oil changes, or new tires. These are all good things to have for your car, but not for insurance to cover. Why should health insurance cover routine or non-emergency health care issues?

Here is where those facts lead, pointing to the beginning of a solution:

Accept that many Americans will work, and most will get their health care through their jobs. Do not fight this legacy: treat it as a feature, not a bug. Plug the gap that exists when people leave a job by allowing them to continue their previous insurance at a greatly reduced rate for a period of one year (maximum, not extendable), with the government picking up most of the insurance tab, like a low-cost version of COBRA. This would also facilitate workers changing jobs and careers, which would enhance mobility. The federal government should also establish certain minimum standards for work-provided health insurance, so it does not turn into a bare bones offering which ends up sending workers to emergency rooms for treatment.
Promote policies which increase access to health care. Remove limitations on health care provided across state lines. Enhance tuition assistance for medical professionals, including reimbursing student debt for those who agree to work in high-need areas or accept Medicaid reimbursement. Provide tax breaks to groups sponsoring wellness and walk-in clinics addressing preventive medicine and routine care. None of these is a panacea, but they are a start at getting more points-of-service for more people.
Establish a national, catastrophic health insurance program. Everyone is automatically enrolled, but this is the ultimate safety net for those who are one day healthy and the next day near death, as well as those with lingering, debilitating conditions. If you have private insurance or can afford to cover your own costs, you are welcome to do so. Run it as an offshoot of Medicaid, with strict rules on what is covered and how service is rationed. Yes, I said it, rationed. Even those who laud health care in Canada or the UK must admit they ration care.
Attack health care cost inflation. Limit the opportunity to sue for medical malpractice and the potential damages, perhaps by direct legislation or placing a significant tax on law firms which profit from the same. Slap a windfall tax on excessive profits for health care providers, medical professionals, or pharmaceutical companies; they can avoid this tax by providing low- or no-cost goods/services to poor Americans. Incentivize average Americans to make full use of preventive care by offering a generous tax credit to those who complete a set of routine tests/services (blood test, flu shots/immunizations, blood pressure, physical, etc.,) annually. Consider additional incentives in the form of government payments into health savings accounts for those who address significant health issues (lose 40 lbs, get $ in your HSA). Empower hospital emergency room physicians to reject non-emergency cases; penalize Americans who use emergency rooms for such care by withdrawing their HSA incentives. The emphasis here is to get Americans to try to stay healthy, mitigating future costs for treatment/prescriptions.
Incentivize states to be the laboratories for new health care policies. Given all the preceding recommendations, there are still gaps for people out of work with health care issues that are neither life-threatening or debilitating. Different states may want to address that gap in different ways. Provide states with block grants that reward programs which identifiable health outcomes (not outputs). Encourage other states to copy successful programs, and defund programs which do not produce such outcomes. If California wants to provide single-payer for its residents, good for them; maybe we can all learn something from that.
Bury, once and for all, the notion of a US-wide single payer system. Countries which have such systems are struggling to pay for them, they ration care, and they have poor deployment of innovative medicine. While the existing US system is sometimes described as heartless and Darwinian, it still produces the greatest array of medical and pharmaceutical innovation in the world. The trick is to retain the benefit of such innovation, while finding a way to reduce the uneven access to good health care at a reasonable cost. Single payer is not the way there.

I have not submitted these concepts to the CBO for a cost estimate, but there is much here to chew on, and I believe it could be tweaked to come in at a reasonable cost. The status quo pre-Obamacare was morally unacceptable; the status quo today with Obamacare is financially unacceptable. The Republicans attempt to repeal and replace Obamacare is DOA mostly because they tried to do it through an obscure Congressional process known as “reconciliation” which limits what could be in the legislation. You can not fix a comprehensive issue with a limited tool kit. The Republicans need to leave Obamacare alone, fully funded as-is for the next two years, and start over with a complete re-work. During those two years, the successes and problems of Obamacare will be evident to even the most ardent partisan, and can inform the development of a bipartisan way forward.