Another government, another round of reorganization and change in the English National Health Service (NHS). When teaching my class in comparative health systems at Duke, one of the things that we highlight about the NHS is the near constant tinkering with the NHS. This tinkering takes place within the context of the overriding big idea of the NHS since its founding in 1948 (care is free at the point of service, with resources distributed based on need). The NHS is primarily tax financed, and they spend about $1 dollar per capita each time we in the US spend $2.50, with societal level outcomes that are certainly more similar than different. One of the primary ways they hold down costs is making access to the primary care part of the system easy, but access to the secondary care (and expensive) portion more difficult. One of the primary tools used to ration services is the use of waiting lists for care.
The most notable thing about the NHS and waiting lists is not that they have them, many nations do, but that they are so explicit and honest about them. For example, one of my children waited 5 months for a diagnostic procedure last year at Duke. I asked the doc about this and he said that the demand for the procedure just outpaced Duke's ability to supply it since it was not an emergency.....that is exactly what a waiting list is. One year in my comparative health systems class I had students research waiting list times in England and at selected hospitals in the US. Waiting lists are much longer in the NHS, but it was often hard to tell. Several students reported encounters like this. How long is the wait to get an X? We don't have waiting lists here. When can I get X? 9 weeks....
One interesting aspect of the NHS for many students is the presence of a private insurance system, in which around 10-15% of the population 'go private' and avoid long waits if they need secondary care that is not of emergency nature. This seems to not only be tolerated, but based on my time as a post-doc in England, it is almost viewed as a way to help out the NHS by getting some secondary care outside of the system. This seems to bother many US undergrads in that it seems unfair. I think it is mostly just a lot more explicit than various differences within the US vis-a-vis health care that are just more subtle. And in any event, the person who lives here gets to do so simply because she was born....so they are in touch with the idea of different social strata.....
Against this backdrop, the new coalition government (Tory and Lib Democrats) has issued a white paper (Liberating the NHS) noting a planned change in policy. This is typical, and most new governments have grand plans for changing the NHS, again within the context of a tax financed system that in one sense is best described as the absence of insurance, and is instead a capitated system in which taxes are collected and distributed from the central government to different levels based on population weighted for certain factors linked to need.
Margaret Thatcher famously claimed to want to dismantle and privatize the NHS; when it was time to run for re-election, she had changed her tune to 'The NHS is safest with us'. John Major, her Tory successor, introduced General Practitioner (GP) fundholding, which introduced a 'purchaser/provider split' and was meant to introduce an internal market into the NHS, with GPs playing a larger role is purchasing hospital care on behalf of their patients. The Tony Blair government focused on modernization and actually explicitly sought to increase spending on a per capita basis, with a goal if increasing the relative spending levels in the NHS to closer to the median for European nations.
The new plan put for by David Cameron, Deputy PM Clegg and their coalition government makes clear the underlying big idea of the NHS is going nowhere. The first point of the document is thus:
*The Government upholds the values and principles of the NHS: of a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay. The second is,
*We will increase health spending in real terms in each year of this Parliament.
This is from the new Prime Minister of the conservative party in England. [As an aside, Margaret Thatcher, beloved of conservatives in the US, would be branded a socialist if she were running for Congress this year, but I digress]
There is lots of typical flourish (Our plan will put patients at the hear of the NHS....), with the actual policy proposals sounding a lot like GP fundholding to me, with a goal of moving control of money from more centralized authorities to groups of GPs who would purchase hospital care for the patients, presumably after and while being more in tune with their patients. The details are still not totally clear. However, it will be the umpteenth round of reorganization and policy change in the NHS. It will be interesting to see what changes are really made,and to what effect.
Here is one source of policy analysis on the White Paper and otherwise, The King's Fund.
Saturday, July 24, 2010
Thursday, July 15, 2010
Supporting ACA and thinking we need to do more on costs
This is my position on the health reform law and is laid out fairly clearly in the columns I wrote on health reform for the Raleigh NC News and Observer (linked on the sidebar). Austin Frakt has a good short post noting this general position, which by the way is the position of many, many health policy types. The ACA was a good first step, in one sense, because it was a step. First, toward covering everyone which is the only hope you have of truly addressing costs after you get rid of the hidden subsidies of our current system in which uninsured folks do get some care. And second, there are aspects of the law that could slow cost inflation to public payers, notably Medicare. Given the history of health policy in the USA, Medicare changes tend to lead to changes in the private system, so this is very important. But, if the ACA is the last step, we won't have a sustainable health care system, and the nation is headed toward bankruptcy as Medicare is the primary driver of the long term structural deficit.
The real questions are: (1) how well will the ACA be implemented, and notably, can the culture of Medicare be changed to move toward adoption of policy changes more rapidly, and develop a culture of trying new things (there will be mistakes). Here is a thoughtful post on Health Affairs blog discussing how Medicare should seek to reduce spending and expand patient benefit. (2) what are the next policy steps that will be taken, especially to address the rate of cost inflation? Capping the tax exclusion of employer paid insurance (at least) is the obvious next step.
But, the biggest question is cultural. Will we Americans grow up and learn to talk about hard things? And face that there are limits to what can be done? During reform I gave a fair number of speeches and events trying to explain what was happening. The crowds had different political persuasions, but there was one similarity to ALL of them. They all agreed we spent too much on health care and needed to spend less (with spend less defined as slow the rate of inflation; less than what we are projected to spend). And when I laid out policies that had a good chance of achieving the goal they all said they shared, they HATED ALL OF THEM. They essentially wanted health reform Disney World style, saving money but making no changes (Disney, after all, has managed to make rape, pillage and murder in the Pirates of the Caribbean ride, a family friendly event!).
I termed this a few weeks ago a culture of delusion. That, more than anything, has got to change for us to have a hope of moving toward a sustainable health care system.
The real questions are: (1) how well will the ACA be implemented, and notably, can the culture of Medicare be changed to move toward adoption of policy changes more rapidly, and develop a culture of trying new things (there will be mistakes). Here is a thoughtful post on Health Affairs blog discussing how Medicare should seek to reduce spending and expand patient benefit. (2) what are the next policy steps that will be taken, especially to address the rate of cost inflation? Capping the tax exclusion of employer paid insurance (at least) is the obvious next step.
But, the biggest question is cultural. Will we Americans grow up and learn to talk about hard things? And face that there are limits to what can be done? During reform I gave a fair number of speeches and events trying to explain what was happening. The crowds had different political persuasions, but there was one similarity to ALL of them. They all agreed we spent too much on health care and needed to spend less (with spend less defined as slow the rate of inflation; less than what we are projected to spend). And when I laid out policies that had a good chance of achieving the goal they all said they shared, they HATED ALL OF THEM. They essentially wanted health reform Disney World style, saving money but making no changes (Disney, after all, has managed to make rape, pillage and murder in the Pirates of the Caribbean ride, a family friendly event!).
I termed this a few weeks ago a culture of delusion. That, more than anything, has got to change for us to have a hope of moving toward a sustainable health care system.
Monday, July 12, 2010
The ins and the outs
have to match for us to have a balanced budget. The co-chairs of the President's Fiscal Commission (Erskine Bowles and Alan Simpson) were talking with the National Governor's Association yesterday. Grim stuff. The key is that the aspect of the deficit driven by the financial crisis is not the major problem--the structural deficit is. That means the deficit that is inevitable given normal functioning of the economy as the baby boomers begin to retire into social security and Medicare. And here is Jon Kyl of Arizona, a Senate Republican leader yesterday saying that tax cuts don't have to be paid for (offset by spending decreases)....as Ezra Klein says some are actually for balancing the budget while others use it simply as a reason to cut certain spending and tax cuts.
A balanced budget means the ins match the outs.
A balanced budget means the ins match the outs.
Saturday, July 10, 2010
Committee to review and update identification of underserved areas
I am honored to have been named a member of the negotiated rulemaking committee that will review and update how medically underserved areas (MUA) and health professional shortage areas (HPSA) are identified and designated. Such designations make areas eligible for receipt of community health center funds, placement of a national health service corps provider, and can make physicians eligible for a Medicare bonus payment. The designations are also used for a variety of other purposes. Here is the federal register notice of intent to form such a committee, from May, 2010. Section 5602 of the Patient Protection and Affordable Care Act of 2010 (the health reform law) provided for the HRSA to review and develop a methodology for identifying such areas, and this committee is the beginning of that process.
My dissertation research, directed by Tom Ricketts at the UNC School of Public Health, and carried out at the Sheps Center for Health Services Research in the Rural Health Research Program, focused on identifying underserved areas and I completed a post-doctoral fellowship at the National Primary Care Research and Development Centre at the University of Manchester (U.K). where I spent a year comparing how the US and the UK conceive of, identify, and respond to 'underserved' areas.
Updated: a little historical context.
My dissertation research, directed by Tom Ricketts at the UNC School of Public Health, and carried out at the Sheps Center for Health Services Research in the Rural Health Research Program, focused on identifying underserved areas and I completed a post-doctoral fellowship at the National Primary Care Research and Development Centre at the University of Manchester (U.K). where I spent a year comparing how the US and the UK conceive of, identify, and respond to 'underserved' areas.
Updated: a little historical context.
Friday, July 9, 2010
Interesting on Chinese health reform
Interesting op-ed sent to me by Lisa Croucher and Randy Kramer in Duke Global Health about health reform in China. My recent post on teaching this past June in China, with some comments on health reform in that nation.
Wednesday, July 7, 2010
Berwick named CMS Director via recess appointment
President Obama will apparently named Donald Berwick to be Director of the Center for Medicare and Medicaid Services (CMS) via a recess appointment later today. This bypasses the need for the Senate to confirm Berwick, but also means that he can only serve in the post until late 2011 at the end of the next Congressional session.
CMS desperately needs a Director to get on with the implementation of the Medicare aspects of the health reform law recently passed, and indeed, many of the demonstrations to be done by Medcare (and Medicaid to a lesser extent) will be tests that will trickle down into the broader health care system as is typical. Most major insurance side innovations in the past 30 years in the U.S. health care system have begun in Medicare and then been adopted by private insurance. Examples include hospice, prospective payment for hospitals and changes in how physician rates have been set.
At a recent health policy conference I attended, there is bipartisan (meaning more liberal and conservative types) that Berwick is a great choice to lead CMS.
More: interesting roundtable discussion hosted by Health Affairs back in April, 2010 about the future of CMS, and issues realted to implementing health reform.
CMS desperately needs a Director to get on with the implementation of the Medicare aspects of the health reform law recently passed, and indeed, many of the demonstrations to be done by Medcare (and Medicaid to a lesser extent) will be tests that will trickle down into the broader health care system as is typical. Most major insurance side innovations in the past 30 years in the U.S. health care system have begun in Medicare and then been adopted by private insurance. Examples include hospice, prospective payment for hospitals and changes in how physician rates have been set.
At a recent health policy conference I attended, there is bipartisan (meaning more liberal and conservative types) that Berwick is a great choice to lead CMS.
More: interesting roundtable discussion hosted by Health Affairs back in April, 2010 about the future of CMS, and issues realted to implementing health reform.
Tuesday, June 15, 2010
Teaching in China
Just back from teaching for the second year in Duke University's joint (along with Peking University) certificate in Global Health, held in Beijing, on the campus of PKUs health science campus. This is the same campus with PKU's "Third Hospital" and just inside the fourth ring road, about 5 minutes by taxi (or 45 minutes depending on traffic) from the Olympic village, Bird's Nest stadium, the water cube, etc. Professor Yan Guo directs the certificate from PKU's end and she is a delightful colleague, who got her start in public health and medicine as a barefoot doctor in rural China.
Around 40 students from all over China took this course. Some of the students were still full time students, while others were physicians, epidemiologists working for the Chinese CDC, and the Office of Quarantine and international travel; the folks who were front and Center dealing with the H1N1 virus and China's response last Summer, and other organizations.
I was teaching a course in comparative health care systems....essentially an overview in financing and structure of how nation's around the world deal with the two 'laws' that govern all health systems in the world: (1) everyone eventually dies; before that (2) the healthy subsidize the sick. The essence of health policy is figuring out how (2) above is done. We began as I always begin my comparative course at Duke, by saying that you cannot copy another countries health system, simply because such systems exist in a particular historical and cultural reality, time and space. But, it can be useful to see what other nation's do, and how it seems to work for them.
China recently announced a plan to move toward covering all Chinese persons with health insurance in January, following 3 basic guiding principles: (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.
China is profoundly on a 'different part of the curve' than is the USA in beginning their reform. The per capita expenditure on health care in China is around $400, with an avg. Life expectancy at birth of around 73 years; the USA has per capita expenditures of over $8,000 per year with life expectancy at birth of around 78 years. So, one thing that China plans to do is spend more, perhaps even much more, on health care services. And they are at a point at which increased expenditures will likely pay off with large health status gains quickly.
As with any per capita expenditure, that doesn't mean that each person gets exactly $400 spent per year on their health care. China probably has upwards of 500 Million people living in very remote rural areas where expenditures are more like $5 per capita (the USA has 310 Million total people). In the large cities of Beijing, Shanghai, and Guangzhou (up the Pearl river from Hong Kong) there are well developed health care delivery systems for persons with either government civil service or private employer based insurance. I think most Americans probably assume that a Socialist nation must have a one-size fits all top/down health care system, but it is really quite the opposite. Many different arrangements, depending upon geography, history, working status and the like. A very common phrase used by students in the course last week was 'we will have to have flexibility to work it out according to local circumstances.' This was especially true when students talked of the rural parts of China. Again, this is the exact opposite of what most Americans would assume.
And Professor Guo explained to me over dinner one evening that at the founding of the People's Republic of China, that the health policy from Mao Tse-Tung held that especially in rural areas, the local people had to decide exactly what type of system they wanted, and they had to fund it themselves. This lead and has lead to wide disparities and spending levels across parts of China, and particularly across different rural portions of the nation. And allowing such local variation and 'working it out' seems to clearly be a part of China's future in health policy.
We talked a great deal in the course about different ways to finance health care services and to collect and pool money (how the healthy subsidize the sick; same idea as car insurance, by the way, and in one sense is simply the definition of insurance). One tremendous demographic change that is underway is China's relaxing of the one child policy. A large increase in the size of a birth cohort would make payroll taxes an attractive way to increase spending, especially for older persons. We walked through the downsides of this approach, especially if later a one child policy is restored....that would make the baby boomer generation look like a small event.
A few other cultural observations, some that relate to health policy, others that do not. First, I enjoyed walking and running in the mornings and evenings and tried to use this time to explore and 'people watch.' There is a huge urban park nearby the PKU health sciences campus and at night, and especially sunday night, there are thousands of people out doing vaguely wholesome things like Karaoke, line dancing, hackey sack, a 50 person brass band playing Presbyterian Hymns, and people singing patriotic songs.
Second, in the mornings, there are many older persons out doing Tai Chi, oftentimes in large groups, especially of women. One thing I admired about this was the seeming lack of self consciousness of the people in doing this in public....I think Americans would feel quite self conscious if out doing such.
Third, there was an empty lot nearby the campus last August when I was there and last week there was a 20 story building there. The rate of construction and development is fast, and there was a construction sight nearby that I am fairly sure was working 24/7.
Fourth, last week had some very large economic events, namely a strike at a plant that supplies Honda with parts for Accords in a southern industrial city. The government appears to have tolerated this strike and to have essentially said that the workers have a point. This along with the widespread report of the doubling of wages in an iPhone factory that had many person's commit suicide appears to signal that the Chinese people are interested in reaping more of the benefits of their rapid economic development. And that the Chinese government either agrees and/or views this as inevitable. This is not surprising, and it part of a transition of China toward a higher income society.
Fifth, I noticed that most obese person's that I saw in China in my walks were young (elementary and middle school age kids). There are some alarming statistics about type II diabetes in China and India and some evidence that type II is onsetting among persons who are not very obese and that it be less amenable to diet and exercise as is the disease in the US. This is also a part of the transition of China to a higher income society.
Sixth, my colleague from Duke, Kate Whetten, taught the course Introduction to Global Health, which is essentially an introduction to health care in low income nations, as well as to a focus on health inequalities in higher income nations. The students were slower to be convinced of the need or benefit of China being involved in the rest of the world. We talked about some of the issues related to criticism of the Chinese government for being slow to respond to the Haiti earthquake...simply put, as China becomes more of an economic leader, the rest of the world expects them to be involved in the rest of the World. My biggest conclusion for the students last week was that China has a tremendous opportunity to not only reform its own health care system, but to be a model for the low income nations of the world who also would like to move to expand financing and expenditure on health care services. Because China is such an economic power, with lots of central infrastructure and ability to implement new polices (it will be slightly easier for Hu Jintao to get what he wants in health reform that it was for President Obama), if China will evaluate what happens and share this with the rest of the world, they have a great chance to be a model and a guide for the nations of Africa, Asia and South America in health reform.
Seventh, they don't have Chinese John Wayne. The hotel I was in only had 1 English TV station and you can only take so much of a business news station so I watched some war movies (there were two or three stations that always had war movies on, with Japan being the primary adversary). The bottom line that was easy to pick up was that the Chinese hero always seemed to die, the city was laid waste, and the concluding scene was one of lament. I kept waiting for the Chinese John Wayne to show up, but he does not exist.
Similarly, last year we went to Chinese opera at the 'egg' which is the name (not the actual name, but you see why they call it this) for the national opera house down by Tiannamen Square. It was a story about a man and his daughter traveling the silk road and his daughter was kidnapped by Middle East traders and she was taken away and married into Middle Eastern royalty. The dad searched for her his entire life and when he found her, filled with rage, he killed her husband, the Prince. Of course, this was his daughter's husband, and filled with sorrow, she killed herself and the story then just ended.
Compare this to the new movie the Karate Kid which I took my kids to see on Sunday....there was never any doubt who would win the last match. If this was a Chinese movie, the karate kid's leg would have been broken, the bad teacher would have killed Mr. Han, and the mom would have committed suicide due to the shame of her son's loss. There is a profound cultural difference between the USA and China in the stories that we tell about ourselves. I am not sure exactly what it means, but I am pretty sure it is important to understanding the relationship betwen the USA and China.
Finally, my bottom line take away from two trips to China and my readings about China is that China defies categorization. It is a jumble of contradictions and unlike any place else in the world. It is simply China. And in thinking about my kids future, when it comes to picking a foreign language to learn in school, there are only two choices that make sense: Spanish or Chinese.
Around 40 students from all over China took this course. Some of the students were still full time students, while others were physicians, epidemiologists working for the Chinese CDC, and the Office of Quarantine and international travel; the folks who were front and Center dealing with the H1N1 virus and China's response last Summer, and other organizations.
I was teaching a course in comparative health care systems....essentially an overview in financing and structure of how nation's around the world deal with the two 'laws' that govern all health systems in the world: (1) everyone eventually dies; before that (2) the healthy subsidize the sick. The essence of health policy is figuring out how (2) above is done. We began as I always begin my comparative course at Duke, by saying that you cannot copy another countries health system, simply because such systems exist in a particular historical and cultural reality, time and space. But, it can be useful to see what other nation's do, and how it seems to work for them.
China recently announced a plan to move toward covering all Chinese persons with health insurance in January, following 3 basic guiding principles: (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.
China is profoundly on a 'different part of the curve' than is the USA in beginning their reform. The per capita expenditure on health care in China is around $400, with an avg. Life expectancy at birth of around 73 years; the USA has per capita expenditures of over $8,000 per year with life expectancy at birth of around 78 years. So, one thing that China plans to do is spend more, perhaps even much more, on health care services. And they are at a point at which increased expenditures will likely pay off with large health status gains quickly.
As with any per capita expenditure, that doesn't mean that each person gets exactly $400 spent per year on their health care. China probably has upwards of 500 Million people living in very remote rural areas where expenditures are more like $5 per capita (the USA has 310 Million total people). In the large cities of Beijing, Shanghai, and Guangzhou (up the Pearl river from Hong Kong) there are well developed health care delivery systems for persons with either government civil service or private employer based insurance. I think most Americans probably assume that a Socialist nation must have a one-size fits all top/down health care system, but it is really quite the opposite. Many different arrangements, depending upon geography, history, working status and the like. A very common phrase used by students in the course last week was 'we will have to have flexibility to work it out according to local circumstances.' This was especially true when students talked of the rural parts of China. Again, this is the exact opposite of what most Americans would assume.
And Professor Guo explained to me over dinner one evening that at the founding of the People's Republic of China, that the health policy from Mao Tse-Tung held that especially in rural areas, the local people had to decide exactly what type of system they wanted, and they had to fund it themselves. This lead and has lead to wide disparities and spending levels across parts of China, and particularly across different rural portions of the nation. And allowing such local variation and 'working it out' seems to clearly be a part of China's future in health policy.
We talked a great deal in the course about different ways to finance health care services and to collect and pool money (how the healthy subsidize the sick; same idea as car insurance, by the way, and in one sense is simply the definition of insurance). One tremendous demographic change that is underway is China's relaxing of the one child policy. A large increase in the size of a birth cohort would make payroll taxes an attractive way to increase spending, especially for older persons. We walked through the downsides of this approach, especially if later a one child policy is restored....that would make the baby boomer generation look like a small event.
A few other cultural observations, some that relate to health policy, others that do not. First, I enjoyed walking and running in the mornings and evenings and tried to use this time to explore and 'people watch.' There is a huge urban park nearby the PKU health sciences campus and at night, and especially sunday night, there are thousands of people out doing vaguely wholesome things like Karaoke, line dancing, hackey sack, a 50 person brass band playing Presbyterian Hymns, and people singing patriotic songs.
Second, in the mornings, there are many older persons out doing Tai Chi, oftentimes in large groups, especially of women. One thing I admired about this was the seeming lack of self consciousness of the people in doing this in public....I think Americans would feel quite self conscious if out doing such.
Third, there was an empty lot nearby the campus last August when I was there and last week there was a 20 story building there. The rate of construction and development is fast, and there was a construction sight nearby that I am fairly sure was working 24/7.
Fourth, last week had some very large economic events, namely a strike at a plant that supplies Honda with parts for Accords in a southern industrial city. The government appears to have tolerated this strike and to have essentially said that the workers have a point. This along with the widespread report of the doubling of wages in an iPhone factory that had many person's commit suicide appears to signal that the Chinese people are interested in reaping more of the benefits of their rapid economic development. And that the Chinese government either agrees and/or views this as inevitable. This is not surprising, and it part of a transition of China toward a higher income society.
Fifth, I noticed that most obese person's that I saw in China in my walks were young (elementary and middle school age kids). There are some alarming statistics about type II diabetes in China and India and some evidence that type II is onsetting among persons who are not very obese and that it be less amenable to diet and exercise as is the disease in the US. This is also a part of the transition of China to a higher income society.
Sixth, my colleague from Duke, Kate Whetten, taught the course Introduction to Global Health, which is essentially an introduction to health care in low income nations, as well as to a focus on health inequalities in higher income nations. The students were slower to be convinced of the need or benefit of China being involved in the rest of the world. We talked about some of the issues related to criticism of the Chinese government for being slow to respond to the Haiti earthquake...simply put, as China becomes more of an economic leader, the rest of the world expects them to be involved in the rest of the World. My biggest conclusion for the students last week was that China has a tremendous opportunity to not only reform its own health care system, but to be a model for the low income nations of the world who also would like to move to expand financing and expenditure on health care services. Because China is such an economic power, with lots of central infrastructure and ability to implement new polices (it will be slightly easier for Hu Jintao to get what he wants in health reform that it was for President Obama), if China will evaluate what happens and share this with the rest of the world, they have a great chance to be a model and a guide for the nations of Africa, Asia and South America in health reform.
Seventh, they don't have Chinese John Wayne. The hotel I was in only had 1 English TV station and you can only take so much of a business news station so I watched some war movies (there were two or three stations that always had war movies on, with Japan being the primary adversary). The bottom line that was easy to pick up was that the Chinese hero always seemed to die, the city was laid waste, and the concluding scene was one of lament. I kept waiting for the Chinese John Wayne to show up, but he does not exist.
Similarly, last year we went to Chinese opera at the 'egg' which is the name (not the actual name, but you see why they call it this) for the national opera house down by Tiannamen Square. It was a story about a man and his daughter traveling the silk road and his daughter was kidnapped by Middle East traders and she was taken away and married into Middle Eastern royalty. The dad searched for her his entire life and when he found her, filled with rage, he killed her husband, the Prince. Of course, this was his daughter's husband, and filled with sorrow, she killed herself and the story then just ended.
Compare this to the new movie the Karate Kid which I took my kids to see on Sunday....there was never any doubt who would win the last match. If this was a Chinese movie, the karate kid's leg would have been broken, the bad teacher would have killed Mr. Han, and the mom would have committed suicide due to the shame of her son's loss. There is a profound cultural difference between the USA and China in the stories that we tell about ourselves. I am not sure exactly what it means, but I am pretty sure it is important to understanding the relationship betwen the USA and China.
Finally, my bottom line take away from two trips to China and my readings about China is that China defies categorization. It is a jumble of contradictions and unlike any place else in the world. It is simply China. And in thinking about my kids future, when it comes to picking a foreign language to learn in school, there are only two choices that make sense: Spanish or Chinese.
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