Counting birds on Nantucket
Bald eagle with its next meal. The species was one of those spotted in the Audubon Christmas Bird Count on Nantucket.
Text from an ecoRI News article
NANTUCKET, Mass. — The sharp, shrill call of a northern saw-whet owl was a welcome sound to the five people, including myself, standing on a soggy trail in the Nantucket State Forest at 5:45 on a chilly, drizzly December morning.
We had gone there specifically to hear the owl — we couldn’t see it, since the sun hadn’t quite risen yet — and log it for the 70th annual Audubon Christmas Bird Count on Nantucket. (If you can hear and identify a bird, you can count it, according to the rules.)
One of our team members for the count had suggested we meet before dawn and head to the state forest to see if we could hear the owl. She hung a small Bluetooth speaker on a tree limb and then played a recording of the owl’s calls. It didn’t respond to the first two, but when she played a third call, a sort of tooting sound, the owl replied. And kept tooting, as if it was delighted to hear a fellow owl.
It was an auspicious start to my first bird count, and it made me realize how seriously birders take the annual event, which has been taking place in the United States for more than 100 years.
Here’s the whole article.
Nantucket from a NASA satellite.
From Pennsylvania Dutch to '60’s graffiti to him
A item by Timothy Curtis in his show“Two Hundred Years of Painting,’’ at The Current, Stowe, Vt., through April 12.
Curtis, a Philadelphian, explores explore the relationships between Pennsylvania Dutch stoneware from the 19th Century, 1960s graffiti writing in the same area and his own artwork, highlighting the thread of influence in one region over 200 years. View original stoneware and new paintings by Curtis, along with a special area dedicated to celebrating the lives and work of 1960s African-American Philadelphia graffiti writers.
The Trapp Family Lodge, in Stowe, founded by the Austrian refugees from the Nazis whose story is the basis of the musical The Sound of Music
— Photo by Royalbroil
Chris Powell: Alphabet people needn’t be so terrified in Conn.
A six-band rainbow flag representing the LGBTQ community. The initials stand for lesbian, gay, bisexual, transgender and queer or questioning.
MANCHESTER, Conn.
Many people are terrified by Donald Trump’s return to the presidency, but perhaps none more so than members of sexual minorities, who lately have commandeered nine letters -- a third of the alphabet -- to construct an acronym with which to represent themselves. The other day an activist among Connecticut's alphabet people told The Hartford Courant that the political climate "continuously demonizes and degrades us" and that Trump wants "to legislatively and socially erase our community."
Really? Is there evidence for such claims, or do they just manifest paranoia, neurosis, hysteria and self-absorption?
For Connecticut isn't darkest South Carolina. To the contrary, it long has been quite libertarian about sexual identity.
In 1971 the state was among the first to repeal its ancient law criminalizing homosexual acts, a law that hadn’t been enforced for many years. To get rid of it little political courage was required from legislators.
In 1991 the state prohibited discrimination based on sexual orientation.
In 2005 the state legalized same-sex "civil unions" and in 2008 same-sex marriage.
While some towns decline requests to fly the "pride flag" at town hall, it’s because the flag constitutes propagandizing for causes government hasn’t endorsed and most people oppose. This is not oppression.
As for Trump, while he, like most people, is against letting men who think of themselves as women participate in women's sports, he has not proposed anything to prevent people from presenting themselves as being of a gender that doesn't match their anatomy. Indeed, though Trump has gotten no credit for it, as a Democratic president would have gotten, his choice for treasury secretary, investment fund manager Scott Bessent, is a gay man married to another gay man, and they have two children.
They live in darkest South Carolina and have yet to be assassinated, and there have been no shrieks of outrage about Bessent from the MAGA crowd.
Trump will prohibit confining in women's prisons men who think of themselves as women, since such practice facilitates rape. But this isn't oppression either; it's safety for women prisoners.
Presumably Trump will oppose letting men use women's restrooms and vice versa, but this traditional policy for gender privacy doesn't obstruct anyone's access to a restroom. When you have to go, you have to go, and you always will be able to.
Amid Connecticut’s political correctness, the restroom issue has gone nutty here, with the General Assembly having required all public schools to put feminine-hygiene products in at least one male restroom. But even without that law, those products would be available in the school nurse's office, and furiously busy as the new president is, it may be a while before he worries about school restrooms in Connecticut.
The alphabet people profess to be terrified that Trump will get Congress to prohibit irreversible sex-change therapy for young people who suffer gender dysphoria. Of course many other people are terrified that some states still don't prohibit such therapy. But objection to it is not oppression but adherence to the principle that minors are not competent to make life-changing decisions. Nor should minors be pressured into such decisions by adults.
Besides, most young people seem to outgrow their gender dysphoria and many others come to regret their irreversible sex-change therapy. Such therapy should wait until young people turn 18.
So what’s left to terrify the alphabet people?
They often hold public rallies complaining of oppression and demanding respect, but the supposed oppressors never show up and nobody gets hurt. Nearly everyone who encounters the rallies passes by in libertarian indifference, the highest form of respect. The demonstrators are in more danger of getting hit by a drunken driver than by a "homophobe," a "transphobe," or a hysteria-phobe.
So the alphabet people should take the chips off their shoulders and live their lives as best they can. While some people could do without their braying, fewer people wish them harm than wish harm to Trump, and the alphabet offers another 17 letters with which they can continue searching for their authentic selves.
Chris Powell has written about Connecticut government and politics for many years (CPowell@cox.net).
The future is political
View in springtime of the Sherman, Conn., end of Candlewood Lake with Candlewood Mountain
“Opinions about the future of society are political opinions.’’
— Malcolm Crowley (1899-1989), American writer, editor, historian, poet and literary critic. He lived for much of his adult life in the exurban town of Sherman, Conn. It has lots of weekend people from New York City.
Good but stern
Ellen Swallow Richards in the 1890’s.
“New England is the home of all that is good and noble with all her sternness and uncompromising opinions.’’
Ellen Swallow Richards (1842-1911), industrial engineer and environmental chemist. She was a native of Dunstable, Mass.
Work-life balance
“Two Women on a Jack” (detail), (metal, tin, wire, wood, and ratcheting jack components), by June Leaf, at the Addison Gallery of American Art, Andover,Mass. (private collection)
— Courtesy Hyphen, New York
Gary W. Rohe: How climate-related insurance woes could break the economy
Photo from roof of high rise in Downtown Los Angeles of Pacific Palisades Fire at peak intensity
Toastt21 photo
MDDDLETOWN, Conn.
The devastating wildfires in Los Angeles have made one threat very clear: Climate change is undermining the insurance systems American homeowners rely on to protect themselves from catastrophes. This breakdown is starting to become painfully clear as families and communities struggle to rebuild.
But another threat remains less recognized: This collapse could pose a threat to the stability of financial markets well beyond the scope of the fires.
It’s been widely accepted for more than a decade that humanity has three choices when it comes to responding to climate risks: adapt, abate or suffer. As an expert in economics and the environment, I know that some degree of suffering is inevitable — after all, humans have already raised the average global temperature by 1.6 degrees Celsius, or 2.9 degrees Fahrenheit. That’s why it’s so important to have functioning insurance markets.
While insurance companies are often cast as villains, when the system works well, insurers play an important role in improving social welfare. When an insurer sets premiums that accurately reflect and communicate risk — what economists call “actuarially fair insurance” — that helps people share risk efficiently, leaving every individual safer and society better off.
But the scale and intensity of the Southern California fires — linked in part to climate change, including record-high global temperatures in 2023 and again in 2024 — has brought a big problem into focus: In a world impacted by increasing climate risk, traditional insurance models no longer apply.
How climate change broke insurance
Historically, the insurance system has worked by relying on experts who study records of past events to estimate how likely it is that a covered event might happen. They then use this information to determine how much to charge a given policyholder. This is called “pricing the risk.”
Many California wildfire survivors face insurance struggles, as this CBS Evening News report shows.
When Americans try to borrow money to buy a home, they expect that mortgage lenders will make them purchase and maintain a certain level of homeowners insurance coverage, even if they chose to self-insure against unlikely additional losses. But thanks to climate change, risks are increasingly difficult to measure, and costs are increasingly catastrophic. It seems clear to me that a new paradigm is needed.
California provided the beginnings of such a paradigm with its Fair Access to Insurance program, known as FAIR. When it was created in 1968, its authors expected that it would provide insurance coverage for the few owners who were unable to get normal policies because they faced special risks from exposure to unusual weather and local climates.
But the program’s coverage is capped at US$500,000 per property – well below the losses that thousands of Los Angeles residents are experiencing right now. Total losses from the wildfires’ first week alone are estimated to exceed $250 billion.
How insurance could break the economy
This state of affairs isn’t just dangerous for homeowners and communities — it could create widespread financial instability. And it’s not just me making this point. For the past several years, central bankers at home and abroad have raised similar concerns. So let’s talk about the risks of large-scale financial contagion.
Anyone who remembers the Great Recession of 2007-2009 knows that seemingly localized problems can snowball.
In that event, the value of opaque bundles of real estate derivatives collapsed from artificial and unsustainable highs, leaving millions of mortgages around the U.S. “underwater.” These properties were no longer valued above owners’ mortgage liabilities, so their best choice was simply to walk away from the obligation to make their monthly payments.
Lenders were forced to foreclose, often at an enormous loss, and the collapse of real estate markets across the U.S. created a global recession that affected financial stability around the world.
Forewarned by that experience, the U.S. Federal Reserve Board wrote in 2020 that “features of climate change can also increase financial system vulnerabilities.” The central bank noted that uncertainty and disagreement about climate risks can lead to sudden declines in asset values, leaving people and businesses vulnerable.
At that time, the Fed had a specific climate-based example of a not-implausible contagion in mind – global risks from sudden large increases in global sea level rise over something like 20 years. A collapse of the West Antarctic Ice Sheet could create such an event, and coastlines around the world would not have enough time to adapt.
In a 2020 press conference, Federal Reserve Chair Jerome Powell discusses climate change and financial stability.
The Fed now has another scenario to consider – one that’s not hypothetical.
It recently put U.S. banks through “stress tests” to gauge their vulnerability to climate risks. In these exercises, the Fed asked member banks to respond to hypothetical but not-implausible climate-based contagion scenarios that would threaten the stability of the entire system.
We will now see if the plans borne of those stress tests can work in the face of enormous wildfires burning throughout an urban area that’s also a financial, cultural and entertainment center of the world.
Gary W. Rohe is a professor of economics and environmental studies at Wesleyan University.
He does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond his academic appointment
Climate change
Llewellyn King: Trump is great news for Russia, China, Iran and North Korea
The sleepy East Richford, Vt.-Glen Sutton, Quebec, border crossing, on the Missisquoi River Bridge. It may become tenser with Trump’s bombastic threats.
WEST WARWICK, R.I.
President-elect Donald Trump is “putting a bit of stick about.”
That is a British expression that means as it sounds to stir up trouble. In sports, like rugby, it means to play more aggressively. In politics, it can mean to stir up trouble for trouble’s sake
Aficionados of U.K. television will remember when, in the BBC version of House of Cards, the prime minister turns to an aide and says with evil relish, “Put a bit of stick about.”
Trump is causing distress, even shock, in the capitals of the North Atlantic Treaty Organization, possibly the most effective alliance that the world has ever known. NATO has been a force for peace since the end of World War II.
Concomitantly, it can be surmised, Trump’s press conference at Mar-a-Largo thrilled the capitals of China, Russia, North Korea and Iran. It would appear to them that NATO is coming apart and what used to be called the Free World is eating its own.
Trump told Denmark that he might invade Greenland, Panama likewise, and Canada that he would use economic measures to compel it to become the 51st state.
Trump’s final bit of stick, if you will, was to suggest re-naming the Gulf of Mexico the Gulf of America, presumably to infuriate Mexicans for no better reason than so many of them have migrated illegally to the United States. Pique, just pique, Mr. President-elect.
Allies and defenders of Trump have rushed to his side, largely depending on their lack of a grip on geopolitical reality or because they believe that he must be right because he is their man, their leader, their sage and America’s savior.
Just how are U.S. interests being served by roiling our two large, friendly neighbors with whom we have lived generally amicably since the end of the hostilities in the War of 1812 for Canada, and the end of the Mexican-American War in 1848 for Mexico?
Trump was enthusiastic about that friendship when he tore up the North American Free Trade Agreement and replaced it proudly with a similar agreement, the United States, Canada, Mexico Agreement, in July 2020, during his first administration.
One can imagine a foolish campaign to seize Greenland, which would tear NATO asunder and give Russia an incentive to invade the Baltic States and, with Europe off balance, to finally win Ukraine.
One could see some future American president eyeing the wreckage and saying, as Richard III wails pathetically in Shakespeare’s play, “A horse, a horse, my kingdom for a horse,” “Europe for Greenland.”
One can imagine Chinese President Xi Jinping taking any U.S. hostile move against a neighbor in North America as an invitation to take Taiwan.
One could go on, imagining Iran launching a full land war against Israel, and Israel responding with nuclear weapons. Or Central and South America, uniting in hostility to the United States, helping their drug gangs to surge fentanyl into the United States via drones and tunnels.
The Panama Canal is a vital waterway, and Americans did build it after the French failed. Since the full transfer of the canal to Panamanian control, in 1999, in accordance with the Torrijos-Carter Treaties of 1977, which guaranteed its neutrality, things have mostly worked well. Yes, China has invested in Panama and the canal, but that is no secret. That was going on, as were other Chinese investments worldwide, during the first Trump administration.
The Chinese do operate two terminals on the canal, but they need the revenue from world shipping, just like any other business along the canal.
The canal remains in our backyard, under surveillance. Interfering with its operations would be an act of war by any country.
If Panama is overcharging U.S. shipping, negotiate.
Leave Canada alone. It is our great asset to the north, our kith and kin in democracy and capitalism. Canadians are not a subjugated people, longing to have two senators and about 60 representatives on the Potomac.
Putting a bit of stick about can be some fun. But take it too far and it becomes vandalism.
Llewellyn King is executive producer and host of White House Chronicle, on PBS. His email is llewellynking1@gmail.com, and he’s based in Rhode Island.
‘Radicalizing the photo’
“Around the Bend’’ (triptych photo), by Lisa Dimondstein, Julie Parker and Sandra Shenk, in their show “Abstract^2,’’ at Mad River Valley Arts, Waitsfield, Vt., in the Green Mountains, through Feb. 28
The gallery says:
“These photographers are dedicated to radicalizing the photo as image. They abstract from an existing abstract sculpture to capture the properties and relationships of the original abstract concept, and in doing so they remove themselves from any context or representation. The photographs are inventive abstractions of sculptures by David Stromeyer. They utilize an in-camera multiple exposure technique to explore the relationship between color, texture, movement, line and form.’’
Preserving the good and the bad of New England mill culture
“Lowell decided that its identity was important. Important to its people and the nation. There are hundreds of people who should be credited for discovering this America. Many workers …wanted to good and the bad of the past preserved, rather than flattened and denied.’’
— U.S. Sen. Paul Tsongas (1941-1997), a Lowell native who was a prime mover in creating the Lowell National Historical Park.
Mass. wants to clean up ‘ghost’ fishing equipment
Sea turtle trapped by abandoned fishing net.
Abandoned fishing gear on the beach.
Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com
“Ghost gear’’ -- abandoned ropes, traps and other fishing equipment on the sea floor -- entangles and kills marine life and makes a mess when it washes up on the shore.
So Massachusetts has commendably enacted a new law that grants the state more authority to remove the gear from the coastal waters over which it has jurisdiction, which means out to three miles from the shore. It has often been hamstrung in dealing with this problem because the stuff, though abandoned, has been treated as private property.
Under the new law, the state Division of Marine Fisheries will develop new regulations to allow for its removal without so much red tape. This will save a lot of animals, from whales down, and will, over time, boost fishing stocks, especially of such groundfish as cod, flounder and haddock.
Borderline cuisine
“Cocktail Teaser” (oil on canvas), by Boston-based artist Campbell-Lynn McLean, in her show “Acquired Tastes,’’ at Bromfield Gallery, Boston, through Feb 2.
David Sterling Brown: Of Trump and Richard III
Earliest surviving portrait of Richard III, from circa 1520.
HARTFORD
Written around 1592, William Shakespeare’s play “Richard III” follows the reign of England’s infamous monarch and charts the path of a charismatic, cunning figure.
As Shakespeare depicts the king’s reign, from June 1483 to August 1485, Richard III’s kingdom was wrought with chaos, confusion and corruption that fueled civil conflict in England.
As a scholar of Shakespeare, I first thought about Richard III and his similarities with Donald Trump after the latter’s debate with President Joe Biden in June 2024. Those similarities – and Shakespeare’s depictions – became even clearer after Trump’s election in November 2024.
Shakespeare’s play highlights the flawed character of a man who wanted to be, in modern terms, a dictator, someone who could do whatever he pleased without any consequences.\
In his 1964 essay, “Why I Stopped Hating Shakespeare,” writer James Baldwin concluded that Shakespeare found poetry “in the lives of people” by knowing “that whatever was happening to anyone was happening to him.”
“It is said that Shakespeare’s time was easier than ours, but I doubt it,” Baldwin wrote. “No time can be easy if one is living through it.”
An undated portrait of Richard III. Universal History Archive/Getty Images?
In Act 2, Scene 3 of Shakespeare’s play, a common citizen says Richard is “full of danger.”
“Woe to the land that’s govern’d by a child,” the citizen further warned.
Beyond hiring murderers to kill his own brother, Shakespeare’s Richard was keen on belittling and distancing himself from people whom he viewed as being not loyal or being in his way – including his wife, Anne.
To clear the way for him to marry his brother’s daughter – his niece Elizabeth – Richard spread what now would be called fake news. In the play, he tells his loyalists “to rumor it abroad that Anne, my wife, is very grievously sick” and “likely to die.”
Richard then poetically reveals her death: “Anne my wife hath bid this world goodnight.”
Yet, before her death, Anne has a sad realization: “Never yet one hour in Richard’s bed / Did I enjoy the golden dew of sleep.”
That sentiment is echoed by Richard’s mother, the Duchess of York, who regrets not strangling “damned” Richard while he was in her “accursed womb.”
As Shakespeare depicts him, Richard III was a self-centered political figure who first appears alone on stage, determined to prove himself a villain.
In Richard’s opening speech, he even says that in order to become king, he will manipulate his own brothers George, the Duke of Clarence, and King Edward IV, “in deadly hate, the one against the other.”
But as his villainous crimes mount up, Richard shares a rare moment of self-awareness: “But I am in / So far in blood that sin will pluck on sin.”
Shakespeare’s Richard III and Trump
While the details of Trump’s and Richard’s lives differ in many ways, there are some similarities.
Much like Trump during his first term, Shakespeare’s Richard did not lead with morals, ethics or integrity.
Richard lied compulsively to everyone, as his soliloquys that contain his innermost thoughts make clear.
An illustration of English writer William Shakespeare (circa 1600). Rischgitz/Getty Images
Like Trump, Richard used empty rhetoric to persuade people with “sugared words” – he was not interested in speaking or promoting truth.
Moreover, Shakespeare’s Richard was a sexist and misogynist who verbally and physically disrespected women, including his wife and mother.
In the play, for example, Richard calls Queen Margaret, widow of King Henry VI, a “foul wrinkled witch” and a “hateful withered hag,” thus disparaging her older age.
He refers to Queen Elizabeth, wife of Edward IV, as a “damned strumpet” or prostitute, which she wasn’t.
Additionally, in order to cast doubts on his nephews’ legitimate claims to the throne, Richard spread false rumors about his mother, claiming that she was unfaithful.
Kamala Harris shakes hands with Donald Trump before their debate. AP Photo/Alex Brandon
For his part, Trump has no shortage of disparaging remarks about women. He once called his Democratic presidential rival Hillary Clinton “the devil” and characterized former U.S. House Speaker Nancy Pelosi as “crazy.”
Trump repeatedly peppered Vice President Kamala Harris during the presidential campaign with sexist and racists attacks.
He initially refused to pronounce her name correctly and openly mocked her racial identity as a Black woman, even questioning her “Blackness.”
A new day?
Like Trump, Richard III used religion to manipulate and confuse public perception of his amoral image.
In the play, Richard stages the equivalent of a modern-day photo op, standing between two “churchmen” with a “prayer-book” in his hands.
Much like Richard, Trump has courted evangelicals and used organized religion to his political advantage, most publicly by selling a “God Bless the USA Bible.”
Trump’s 2020 photo op in front of St. John’s Church in Washington is another example. It occurred during protests over the murder of George Floyd, an unarmed Black man killed by a white police officer. Police in riot gear used tear gas to force protesters away from the White House; then Trump was escorted to the nearby church along with several administration officials.
As a political leader, Richard III left a legacy in English history as one of England’s worst monarchs.
That legacy includes his decisive defeat in the Battle of Bosworth Field in 1485 that led to his death and to a new era for England under King Henry VII.
After winning the throne, the new king offered a message of hope that suggested England would one day emerge from its time of civil discord:
Let them not live to taste this land’s increase That would with treason wound this fair land’s peace!
Now civil wounds are stopped, peace lives again. That she may long live here, God say amen.
David Sterling Brown is an associate professor of English at Trinity College in Hartford.
He receives funding from the Mellon Foundation and American Council of Learned Societies.
In the dim
“Edge of the Pond” (oil on canvas) (circa 1910), by Robertson Kirtland Mygatt, in the show ‘“Dawn and Dusk: Tonalism in Connecticut,’’ at Fairfield (Conn.) University Art Museum opening Jan. 17.
Jokes between strips
“The Naked i, one of the old Boston Combat Zone's larger strip clubs.’’
— Photo by Peter Vanderwarker
“Back in Boston, I discovered the great starting ground for so many comics: strip clubs! Since the early days of burlesque, these places always had a guy come out and tell jokes between every dancer’s turn onstage. I guess it was supposed to break the horrible monopoly of ogling bare flesh.’’
Jay Leno (born 1950), American TV host and comedian. He grew up in Andover, Mass.
Llewellyn King: My frightening, splendid Christmas in a Rhode Island emergency room
Photo by Peachyeung316
WEST WARICK, R.I.
Most people have horror stories about emergency rooms. Whether it is in Boston, Washington or Los Angeles, the stories are appalling.
Gurneys, sometimes with critically ill patients, lined up and left unattended along walls. Hurting people waiting for hours because of a shortage of staff, a shortage of beds, and a prevailing shortage of resources. Systems that are stressed and seem to be near breaking point.
Well, I have a story about my recent ER visit, which was pure joy and likely saved my life.
The story begins just before Christmas with my travels on crowded Amtrak trains and even more crowded airplanes.
I was wearing a mask during these trips, and had gotten flu and Covid shots, but I caught the flu. I received prompt and proper treatment for it, but I wasn’t licking it.
The Saturday before Christmas, early in the morning, I was having a fever hallucination: I sat bolt upright in bed and told my wonderful wife, Linda Gasparello, that I was preparing my maiden speech to the British House of Commons.
As I haven't set foot in the U.K. parliament for years, and then only in the press gallery, this insane bravado led her to call an ambulance at around 2 a.m. — over my protests that I was getting better, and taking a Tylenol would take care of everything. “Just you see,” I said.
What Linda saw was a very sick man clearly delirious and in need of urgent medical help.
Kindly men from the West Warwick, Rhode Island Fire Department’s ambulance service quietly entered our apartment and wafted me into the ambulance, where they checked my vital signs, did an electrocardiogram, and other work. I was in good, strong, comforting and knowledgeable hands.
When they were done, they drove me a few miles to Kent Hospital, part of Care New England, which has the second-busiest ER in the state. Not auspicious? Read on.
I wasn’t parked along a wall or interrogated about my insurance, but rushed straight to waiting nurses and the emergency medical technicians stood by until I was hooked up to an IV and a doctor had seen me. Shortly afterward, I was seen by two doctors.
Emergency rooms are, by all accounts, hellholes. I expected the worst, but I got two days of excellent care and pleasant attention. I have stayed at some of the best hotels in the world, including the Carlyle, in New York, the Ritz, in Paris, the Hassler, in Rome, and Brown’s, in London, and I had the same feeling of wellbeing at the Kent Hospital ER — people who cared and told me they were just a bell-ring away.
When my vitals were stable in a couple of days, I was invited to participate in a unique and remarkable system called “Kent Hospital at Home.”
Under this system (some form of which is operational at nearly 400 hospitals in 39 states), select patients can go home without being discharged, and the home becomes a hospital room. You are hooked up with a monitor, which sends data about your vitals to ER nurses. You can read these on an iPad, which also has contact information for the nurses and doctors assigned to you. You also get an emergency alarm on a wristband.
Everything the patient might have needed in the hospital is transported to the home. This might include an IV, oxygen, and other necessary equipment that might be used in the ER.
Best of all, you get visits twice a day by a nurse and once a day from a physician, either in person or virtual. I was in the system for just two days before discharge and saw the doctor in my home once and on Zoom once. I was given his cell phone number with instructions to call whenever I needed to.
The hospital-at-home concept was pioneered by the Mayo Clinic, among other medical facilities, during the Covid-19 pandemic. It has a waiver from Medicare, which means that you are billed as an in-hospitable patient not an outpatient.
Kent Hospital emphasized that when they moved me from the hospital to my home — in their vehicle — it was a “transfer” not in any way a discharge.
Research suggests that hospital-at-home care saves the provider between 19 percent and 30 percent on keeping the same patient in the hospital.
I am grateful to all who played a role in my recovery, from the ambulance crew to the emergency nurses, doctors, radiologists and porters.
Also, I am grateful for an insight into how medicine should work and how it will be enhanced in the future through technology of the kind that makes hospital-at-home care possible and viable.
For the record, I had Influenza A and sepsis pneumonia.
I had magnificent treatment and thank all who handed me a Christmas present beyond value. And I even saw a doctor making a house call. I wasn’t hallucinating.
Llewellyn King is executive producer and host of White House Chronicle, on PBS. His email is llewellynking1@gmail.com. and he’s based in Rhode Island.
The cold fends them off
“I am lingering in Maine this winter, to fight wolves and foxes. The sun is less strong than Florida’s, but so is the spirit of development.’’
— Essayist and children’s book author E.B. White (1899-1985), in “A Report in January’’ (1958). He lived for many years on a farm in Brooklin, Maine.
Dressed for hydraulics
“Flood Drought Sisters,’’ by Cori Champagne, in her show “Water Mgmt,’’ at Boston Sculptors Gallery through Jan. 26.
Edited from commentary by the gallery:
“Cori Champagne's exhibition features a new series of functional garments addressing our most precious resource. Intended to navigate shifting hydrological cycles, Champagne’s hand-made clothing resembles streetwear, but is designed to collect, store and distribute water in preparation for a changing eco-future.
“At the center of the exhibition, ‘Flood Drought Sisters’ posits the extremes of floods and droughts in a more advantageous relationship to one another. The exquisitely crafted rainwear for Champagne’s ‘Flood’
ensemble gathers rainwater into a series of funnel-like flower forms protruding from the back and shoulders. Collected in modular containers, the rainwater can then be transferred, transported, and utilized via the wearable storage provided by the complementary ‘Drought’ garment. The two figures face each other, inviting viewers to appreciate various details in their creation, including the upcycling of ExxonMobil coveralls in the ‘Flood’ vest. A short video expands on the narrative. Shot with the artist in multiple locations, it further illustrates the symbiotic nature of both sides of the piece.
Llewellyn King: Trump’s law-of-the-jungle approach to foreign policy
Map shows how the U.S.-British Webster-Ashburton Treaty of 1842 resolved a border dispute that had threatened to to lead to war.
WEST WARWICK, R.I.
When Donald Trump began his first term as president, in 2017, I wrote that he came to office not as a politician who had won an election, but rather as a businessman who had won a takeover battle and was ready to hire, fire, sell-off, and generally to reshape the property he had bought.
On Christmas Day, Trump – with a series of posts on social media — revealed himself as a businessman who believes not that he has won the nation in a takeover battle, but rather that he has won the whole world and that he is ready to hire, fire and sell-off.
Also, like a canny takeover artist, he didn’t reveal his hand during the takeover struggle. During the election, there was no assertion from him that Canada should become the U.S. 51st state, that Panama was overcharging U.S. shipping or that ownership of Greenland was essential over and above the key role it already plays with a vital U.S. base, happily provided for by treaty with Denmark.
Like a businessman, Trump offered to buy Greenland during his first presidential term. His offer was soundly and summarily rejected. Now he is back and the answer hasn’t changed.
Canada, Trump believes, takes unfair advantage of the United States in trade, although the regime of the flourishing cross-border trading is the selfsame one: the United States-Mexico-Canada Agreement, signed in July 2020 by Trump himself as a vast improvement over its predecessor, the North American Free Trade Agreement, although in substance and spirit it is very similar.
When it comes to Panama, Trump has a double accusation. Beyond the belief that Panama is ripping us off, this kind of national business paranoia is part of the Trump manual of expectations in foreign policy: All foreign governments are scalawags bent on cheating America.
It is part of a kind of permanent, low-grade C-Suite paranoia that is present in many companies: Who is stealing an advantage, who is going to concede to the unions, who is angling for more shelf space, etc. You might call it corporate situational awareness paranoia.
Statesmanship is learned; good instincts help, but it isn't intuitive for most leaders. It is learned through studying history, meeting, talking, traveling, and moving in foreign policy circles. It is learned best on the job, if the job is in the House or the Senate.
Trump has learned not in that world, but in the world of New York real estate with its own jungle law — deals are done, undone, litigated, and political influence is brought to bear. Ultimately, there is victory for one side.
Trump correctly — and it could be said belatedly because he took no action during his first administration — has cast a penetrating light on China in the Americas. Trump has erroneously said that China runs the Panama Canal. No, Panama does. A subsidiary of Hong Kong-based CK Hutchison Holdings manages two ports at the canal's entrances, with Chinese firms providing more than $1 billion for the construction of a new bridge over the canal.
Panama’s revenues are up as a result of congestion charging, but fewer ships are transiting the canal due to drought. The vast Lake Gatun, which feeds the canal and keeps the lock system viable, is only partially full. The less water available, the fewer transits are possible. These dipped from 38 large ships to just 22 but rains have recently improved the situation and transits have risen.
Seizing canals is a fraught business, witness the disaster of France and Britain trying to seize the Suez Canal in 1956. Major damage to the Panama Canal would cost the United States for decades. It is a masterpiece of big, intricate engineering. I took a cruise through it for the purpose of understanding it better.
The British word “gobsmacked” is easily understood: smacked in the mouth. That is what happened to the commentariat — those who comment on national affairs. Trump’s Christmas Day declarations on Truth Social, his social-media network, went almost unmentioned. The reporting was there, the networks and newspapers turned up the volume, but the commentators were silent,
That, in its way, is as notable as Trump’s implication that he has bought the world and plans to take possession. We, the opinion writers, have been struck dumb, you might say. That is news in itself.
On Twitter: @llewellynking2
Llewellyn King is executive producer and host of White House Chronicle, on PBS, and he’s based in Rhode Island.
White House Chronicle
James B. Rebitzer: Market concentration by CVS and other PBM’s helps boost drug prices
BOSTON
Wegovy and Ozempic are weight-loss drugs that promise to transform the treatment of obesity, heart disease and other chronic conditions that afflict millions of Americans. But while everyone agrees these drugs have the potential to transform lives, no one can agree on how best to pay for them.
Wegovy sells for a list price – or price before discounts – of $1,349 per month in the U.S. The same drug lists for $265 in Canada and less than half of that in the U.K. These dramatic differences illustrate a larger issue: The list price of patented drugs in the U.S. are far higher than in other rich countries.
U.S. Sen. Bernie Sanders (I-Vermont) spoke for many Americans when he said the high cost of drugs in America was “not just an issue of economics” but rather “a profound moral issue.”
Moral outrage leads to a search for villains. Joe Kernan, host of CNBC’s business show Squawk Box, cut to the chase when he asked: “Who is screwing us here? The PBMs? The drugmakers?”
As a health economist who writes about innovations in the health sector, I have spent a good portion of the past five years thinking about these questions. What I’ve learned is that high list prices for drugs don’t tell us much about who is screwing whom. To truly understand the problem of drug pricing in the U.S., you need to start with the tricky economics of the PBMs, or pharmacy benefit managers.
Pharmacy benefit managers started popping up in the late 1960s as providers of claims processing and administrative services for health insurers. Over time, they became essential middlemen between drugmakers and the many insurers, employers and government entities who purchase drugs on behalf of their members, constituents and beneficiaries.
Mergers between PBMs have led to a market dominated by a small number of very large players. In 2023, the three biggest ones – OptumRx, Express Scripts and CVS Caremark – managed 79% of U.S. prescription claims and served roughly 270 million customers. (CVS is based in Woonsocket, R.I.)
The primary role of these companies is to negotiate price, affordability and access to prescription drugs. They do this by operating and designing formularies, which are lists of drugs that insurers cover.
A drug’s listing on a formulary determines its price. Joe Buglewicz/The Washington Post via Getty Images
Formularies also assign drugs to different tiers that determine what patients must pay out of pocket to access the drug. Generic drugs are typically placed in the tier with the lowest out-of-pocket costs. Patented drugs that insurers prefer are placed in a tier with higher costs, and nonpreferred drugs are in a tier that requires patients to pay even more. Some drugs can even be excluded from the formulary altogether, meaning insurance won’t cover them.
Tier placement determines how affordable a medication is to consumers and the effective drug price that insurers pay. Drugmakers compete with each other for placement on desired formulary tiers by offering PBMs significant discounts off their list price. The price at which the PBM obtains the drug for its clients is the net price – the list price minus the drugmaker’s discount.
If a drugmaker increases its rebate, the net price falls, even if the publicly posted list prices remain high. This is why focusing on list prices to determine the cost of a drug can be misleading.
The price is right?
List prices for drugs are public knowledge, but drugmakers’ discounts to PBMs are closely held secrets. As a result, it’s hard to know exactly how much insurers pay for most prescription drugs.
This secrecy raises challenging questions. Do PBMs use their size and negotiating power to win lower net prices from drugmakers? Or do PBMs use their dominant market position and opaque business practices to enrich themselves at the expense of their customers and the rest of society?
The answer to both these questions is, surprisingly, yes. If the contest for formulary placement works as it should, competition compels drugmakers to offer substantial discounts off the published list price. As a result, insurers and consumers benefit from a reduced net price for drugs. However, formulary competition can be undermined in various ways.
In a 2024 report, for example, the U.S. Federal Trade Commission found evidence that the manufacturer of a patented form of insulin offered higher rebates to a PBM if competing insulins were placed on a less favorable tier of a formulary or excluded altogether. This arrangement reduces consumer choice. If a cheaper generic equivalent is excluded, the arrangement would also favor a more expensive drug that raises patient costs. Widespread use of such exclusionary rebates might even discourage new generics and reduce competition.
Introducing biosimilar drugs manufactured specifically for PBMs to substitute for expensive biologics manufactured elsewhere can also undermine formulary competition. When PBMs favor their in-house products in formularies, this reduces the incentive for other drugmakers to introduce competing products. The result is both less competition and higher prices.
Competition within the formulary can also be distorted when drugmakers post very high list prices. This artificially inflates rebates for PBMs without lowering net prices for insurers and other parties. Inflated list prices also increase the cost of drugs for some groups of patients – notably, people who lack health insurance or have high deductible plans.
Market competition
Just as fair competition can break down within the PBM’s formulary, it can also fall apart in the market for PBM services.
The current regulatory environment in the U.S. tolerates overly large PBMs that engage in anticompetitive practices to accumulate excessive profits. Without strong competitors, dominant PBMs are free to charge their customers high fees and keep a larger portion of drugmaker rebates for themselves.
In theory, this problem should be self-correcting. High profits should attract new competitors into the industry. Competition from these entrants should lower fees and reduce the fraction of rebates these companies keep. However, things work out differently in practice because the largest PBMs have merged with the largest health insurers. CVS has merged with Aetna. Express Scripts and OptumRx merged, respectively, with Cigna and UnitedHealthcare. These combinations reduce the number of potential customers for new PBMs and so keep new competitors from entering the market.
CVS Health has its own PBM (CVS Caremark), pharmacy chain (CVS Pharmacy) and health insurer (Aetna). Charles Krupa/AP Photo
Scrappy upstarts that could shake up the status quo also find themselves at a disadvantage due to common contracting practices. Large PBMs, for example, often insist on “most-favored-nation” contracts that require drugmakers to meet or beat the prices they offer to other buyers. These contracts eliminate the competitive advantage a new PBM might gain from obtaining better prices than incumbent companies.
There is growing concern among experts that dominant PBMs also use formularies to steer profitable “specialty prescriptions” to pharmacies with whom they are affiliated. The pharmacies affiliated with the three biggest PBMs expanded their share of the specialty drug market from 55% to 67% between 2016 and 2023. Concerns over such anticompetitive practices have led to bipartisan legislation to force PBMs to sell off their retail or mail-order pharmacies.
Who are the villains?
So, are PBMs screwing us? If we didn’t have PBMs, we would need to invent them – or something like them – to obtain reasonable prices on patented drugs. But the concentration of market power among a few companies threatens to dissipate the value they create.
Increasing competition within the PBM marketplace will likely require a larger number of smaller PBMs, and large insurers may also be required to divest their PBM units.
Contrary to conventional wisdom, smaller PBMs will likely be just as able to negotiate a low net price for Wegovy and other patented drugs as larger PBMs. Beyond a certain minimum scale, it is competition for formulary placement, not PBM size, that matters. A more competitive and transparent market for PBM services will help keep that contest fair and transparent – to the benefit of customers and society.
In that sense, PBMs aren’t the villain. Too much market power in too few hands is the problem, and that’s something more competition, sensible regulation and vocal consumers might fix.
James B. Rebitzer is Wexler Professor of Management, Economics and Public Policy at Boston University
He does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.