Major Changes Proposed for Family Planning Grants

A few weeks ago HHS issued new proposed regulations for Title X (family planning) grants in the Federal Register. The new regulations would make many changes to the requirements for Title X projects and could profoundly change how family planning services are provided by significantly limit the network of providers who can qualify for funds; restricting the ability of participating providers from discussing and referring for abortion; and making other programmatic changes that could dramatically reshape the program and provider network available to low-income women.

If fully implemented, the proposed changes to Title X would shrink the network of participating providers and have major repercussions for low-income women in AZ that rely on these services for their family planning care.

Here’s an informative Issue Brief about the planned changes. The new proposed regulations and the place to submit comments are up on the Federal Register website through July 31.

Courts Overrule CMS’ Approval of KY’s Medicaid Work Requirements- Ruling Could Influence AZ’s Request

Kentucky was the first state to have a work requirement waiver approved by CMS (it was set to take effect yesterday- July 1, 2018).  But last Friday, a federal District Court Judge ruled that Kentucky’s CMS approved waiver which would have implemented work/community engagement requirements failed to address the purpose of the Medicaid program- to provide coverage and care. Medicaid is obligated under federal law to consider whether a waiver proposal advances the program’s objectives. 

Specifically, toward the end of the Decision, the court concludes that “…the Secretary must adequately consider the effect of any demonstration project on the State’s ability to help provide medical coverage. He never did so here.”  

When you read the Decision, you’ll see that the court basically concluded that when CMS approved the waiver, they didn’t consider its impact on the primary objective of the Medicaid program- which is to provide medical coverage and care. The court vacated CMS’ approval of the waiver and remanded it back to HHS (CMS).

While Kentucky’s waiver request isn’t exactly the same as  Arizona’s work and community engagement waiver request, there are many similarities. Both require some Medicaid members to meet work or community engagement requirements (AZ has more exempted populations than KY), both have reporting requirements, and both include lockout provisions for folks that don’t comply. The specific standards and exemptions are different, but both include the same basic requirements (except that KY includes some premium payments- which isn’t included in Arizona’s waiver request). 

This is certainly the beginning of a longer legal battle, but last week’s Ruling could very well influence CMS’ upcoming decision about whether (or when) to approve Arizona’s waiver request.

Legal Defense of the Affordable Care Act

A few months ago, Texas and 19 other states (including AZ) launched a new legal effort to eliminate the Affordable Care Act.  Fortunately, California and 15 other states intervened as defendants in the lawsuit, because they were worried that the President’s administration wouldn’t defend the ACA.

Earlier this month the Department of Justice filed a pleading that agreed with TX, AZ and the other 18 states.  Instead of defending the ACA as is customary, the DOJ argued that several crucial provisions of the ACA are unconstitutional and announced that it would not defend those provisions in court (3 career DOJ attorneys removed their names from the brief and one quit a few days later).  CA and other states will be defending the ACA and argue on its behalf in court. 

If the Intervenor states lose the case, insurers could invoke pre-existing conditions to refuse coverage or increase premiums and could underwrite coverage based on gender, age, and occupation.  

Here’s a useful summary of the case written by the National Health Law Program.

Cannabis v. Marijuana

 

Are Marijuana and Cannabis the same thing when it comes to Arizona Law?  The short answer is maybe not- and the distinction may be an important one for Qualified Medical Marijuana Patients in AZ.

The Arizona Medical Marijuana Act provides qualified patients and dispensaries a number of legal protections under the voter approved  Act.  Interestingly, the Arizona Medical Marijuana Act definition of “Marijuana” in A.R.S. § 36-2801(8) differs from the Arizona Criminal Code’s definition of “Marijuana” in A.R.S. § 13-3401(19). In addition, the Arizona Medical Marijuana Act makes a distinction between “Marijuana” and “Usable Marijuana” A.R.S. § 36-2801(8) and (15).

The definition of “Marijuana” in the Arizona Medical Marijuana Act is: “… all parts of any plant of the genus cannabis whether growing or not, and the seeds of such plant.”  The definition of “Usable Marijuana” is “…  the dried flowers of the marijuana plant, and any mixture or preparation thereof, but does not include the seeds, stalks and roots of the plant and does not include the weight of any non-marijuana ingredients combined with marijuana and prepared for consumption as food or drink.”  The “allowable amount of marijuana” for a qualifying patient and a designated caregiver includes “two-and-one half ounces of usable marijuana.”  A.R.S. § 36-2801(1)

The definition of “Marijuana” in the Criminal Code is “… all parts of any plant of the genus cannabisfrom which the resin has not been extracted, whether growing or not, and the seeds of such plant.”   “Cannabis” is defined as: “… the following substances under whatever names they may be designated: (a) The resin extracted from any part of a plant of the genus cannabis, and every compound, manufacture, salt, derivative, mixture or preparation of such plant, its seeds or its resin.  Cannabis does not include oil or cake made from the seeds of such plant, any fiber, compound, manufacture, salt, derivative, mixture or preparation of the mature stalks of such plant except the resin extracted from the stalks or any fiber, oil or cake or the sterilized seed of such plant which is incapable of germination; and (b) Every compound, manufacture, salt, derivative, mixture or preparation of such resin or tetrahydrocannabinol.” A.R.S. § 13-3401(4) and (20)(w)

This distinction is an important one for medical marijuana patients and dispensaries.  This week the AZ Court of Appeals in State v. Jones held that a medical marijuana cardholder was in possession of “hashish”, which he received for free when an employee at a marijuana dispensary in Phoenix had given it to him (the Act specifically allows for gifts of this size between patients). The case involves a transaction between two individuals and doesn’t address a transaction between a dispensary and a patient.

The court held that hashish is a resin extracted from the marijuana plant and therefore is Cannabis as defined in the criminal code. The case begs for an appeal.  It doesn’t mention concentrates or vape cartridges, and it states that the Arizona Medical Marijuana Act protects patients in possession of allowable amounts of mixtures or preparations of medical marijuana… but it does call into question what protections patients have for what substances as well as what kinds of products are allowable for sale at dispensaries. 

I expect to see the Arizona Supreme Court quickly take up the case (and soon), as the ruling certainly needs to be resolved quickly- and only the Arizona Supreme Court is in the position to make the final call.

It’s too bad that a patient had to spend a year in jail for this issue to be resolved.

AzPHA Policy Update: Child Separation, Government Restructuring, House Health Budget Bill

APHA Policy Statement on Child Separation

More than 2,300 children have recently suffered the traumatic experience of being forcibly separated from their parents by the federal government.  Despite the fact that the president has issued an Executive Order to end the practice, thousands of kids are currently separated from their parents.  Some of them are in various facilities in Arizona.

The American Public Health Association (our parent organization) issued a statement last week regarding the policy of child separation recently implemented (and now suspended) by the federal government.  Rather than paraphrase- I thought I’d just block and paste it below:

“The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future. 

“As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.

“More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.

“Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.

“There is no law requiring the separation of parents and children at the border. This policy violates fundamental human rights. We urge the administration to immediately stop the practice of separating immigrant children and parents and ensure those who have been separated are rapidly reunited, to ensure the health and well-being of these children.”

 

AZ’s System for Regulating the Facilities Caring for Separated Children

Some of the children that have been separated from their parents by the federal government are being cared for in AZ at places run by an organization named Southwest Key. There are 13 such facilities in AZ.  They’re licensed by the Arizona Department of Health Services and classified as Child Behavioral Health Facilities.  Even though they’re licensed by the ADHS, the agency doesn’t conduct routine unannounced inspections at them because they’re accredited by the Council on Accreditation.

Arizona law says that when a facility like this is accredited by an appropriate independent body, the ADHS shall accept the accreditation in lieu of a routine agency inspection. Specifically, ARS 36-424 (B) states that: “The (ADHS) director shall accept proof that a health care institution is an accredited health care institution in lieu of all compliance inspections required by this chapter if the director receives a copy of the institution’s accreditation report for the licensure period”.

However, the ADHS still has an obligation to investigate complaints at these facilities because ARS 36-424 (C) says that: “On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter… (the ADHS) may enter on and into the premises…  for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules.”

You can view the status of these facilities at www.azcarecheck.com and search for the words Southwest Key.  You’d be able to see the results of any complaint investigations or enforcement actions against these facilities- but not the backup accreditation documents from the Council on Accreditation.

 

Supporting Separated Children & Parents

A publication called “Child Trends” put out a blog last week entitled Supporting Children and Parents Affected by the Trauma of Separation that contains evidenced-based guidance for parents and officials.  Hopefully some of the persons within the federal government and care facilities are familiar with and are applying this important information (like Trauma Informed Care) in their policies and procedures like:

 

Federal Government Restructuring Proposed by President

Last week the President Trump unveiled a wide-ranging plan to reorganize many functions within the federal government.  The proposal is posted on the White House website.  It’s 132 pages long- but it’s formatted in a way that’s easy to follow – with an index and formatting that makes it easy to read.

It proposes reorganizing various federal government functions in a wide range of programs.  For example, it proposes creating a new Federal Food Safety Agency that would absorb the various USDA and FDA food safety programs- moving everything to a stand-alone food safety agency.

WIC and SNAP would move out of the USDA and into HHS. Environmental programs at the Department of Interior and the USDA would move over to the EPA.  It also proposes reducing the size of the US Public Health Service Commission Corps from 6,500 officers to 4,000 officers with a Reserve Corps for public health emergencies.  It also plans to merge the Education and Labor Departments to consolidate work force programs.

There are many, many other proposals, like privatizing the US Postal Service.

So far this is just a proposal from the President and his team.  Any such restructuring would need to be authorized by congress.  Here’s a link to the wide-ranging report.  Of course, we’ll continue to track the public health portions of this.  It seems super-unlikely to see any action before the November election.

 

Federal FY 19 Health-related Budget Bill

The House Labor, Health and Human Services, and Education Appropriations Subcommittee released the FY19 House Appropriations report. The bill includes $177B in discretionary funding, which is essentially the same as FY18.  Here’s a summary:

CDC

The bill proposes total funding level of $7.6 billion, or $663 million decrease from FY18, but most of the decrease is due to the transfer of the strategic national stockpile to another part of HHS.

HRSA

The bill proposes a total funding level of $6.5 billion, a $196 million decrease from FY18. Title X Family Planning funding would be eliminated completely.  Primary Health Care would get a 7% decrease.

SAMHSA

The bill proposes a total funding level of $5.6 billion for SAMHSA, a $448 million increase above FY18, mostly because the Substance Abuse Block Grant and the State Opioid Response Grants would be significantly increased.

Policy Update: Family Planning, ACA Lawsuit, Work Requirements and Assault Weapons

Summer & Fall Public Health Activities in AZ

Interested in finding out about the various public health conferences, meetings and events this Summer and Fall?  

Bookmark our AzPHA Upcoming Events webpage.  It’s as simple as that.  If I’ve missed something- let me know at [email protected]!

 

Proposed Title X Funding Changes Likely to be a PH Burden

The US Department of Health and Human Services has proposed changes to the rules for the federal family planning services program, known as Title X.  If the new rules are adopted as proposed, it’ll require Title X family planning services to be physically and financially separate from abortion services.

Many family planning clinics offer both family planning and abortion referral services, and if the changes are ultimately implemented many of the programs would likely decide not to take Title X funding, which would have a big impact on the network of available services and they’d have fewer resources available for STD screening, treatment and outreach.

BTW: Title X funds have never been allowed to be used for abortions. The proposed rule is available for public comment until the end of July.  You can read more about the proposed rule and comment by visiting the Federal Rulemaking Portal: http://www.regulations.gov. Just follow the instructions to submit.  Your comments might not influence the outcome, but at least you’ll have done your part. That and voting this Fall.

 

Federal Government Won’t Defend the Affordable Care Act in Court

So far, the Affordable Care Act has survived the 2 court challenges that made it to the US Supreme Court.  Back in 2012 the ACA was upheld by the Supreme Court for the first time (by a 5-4 margin) in the National Federation of Independent Business v. Sebelius case.   It was upheld again in 2015 when (in a 6-3 decision) the Supreme Court upheld ACA’s federal tax credits for eligible Americans living in all 50 states (not just the 34 states with federal marketplaces).

But, there are additional challenges out there that haven’t made it to the Supreme Court yet. One that’s progressing through the courts is a challenge filed by 20 states (including Arizona) arguing that the ACA’s individual mandate is unconstitutional and key parts of the act — including the provisions protecting those with pre-existing conditions — are invalid. 

This week Attorney General Jeff Sessions acknowledged that while “the Executive Branch has a longstanding tradition of defending the constitutionality of duly enacted statutes if reasonable arguments can be made in their defense,” the Attorney General will not defend the ACA from this challenge.  

The implications could be profound.  The ACA could potentially be completely overturned- or portions that require health plans to cover pre-existing conditions could be eliminated along with the mandate that persons have health insurance.

 

Medicaid Work/Community Engagement & Reporting Requirements

Any day now, the Centers for Medicare and Medicaid Services (CMS) will be approving Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment.  The request filed by AHCCCS is required by Senate Bill 1092 (from 2015) which requires them to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”.

AHCCCS initially proposed implementing the following requirements for able-bodied adults receiving Medicaid services including: 1) a requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program; 2) requiring able-bodied adults to verify monthly compliance with the work requirements and any changes in family income; 3) banning an eligible person from enrollment for one year if the eligible person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements; and 4) limiting lifetime coverage for all able-bodied adults to five years except for certain circumstances.

Hundreds of comments were submitted (including comments from AzPHA) urging the agency to consider modifications to the initial waiver request.  AHCCCS later issued a final waiver request which includes exemptions for:

  • Those who are at least 55 years old;
  • American Indians;
  • Women up to the end of the month in which the 90th day of post-pregnancy occurs;
  • Former Arizona foster youths up to age 26;
  • People determined to have a serious mental illness (SMI);
  • People receiving temporary or permanent long-term disability benefits from a private insurer or from the government;
  • People determined to be medically frail;
  • Full-time high school students older than 18 years old;
  • Full-time college or graduate students;
  • Victims of domestic violence;
  • Individuals who are homeless;
  • People recently been directly impacted by a catastrophic event such as a natural disaster or the death of a family member living in the same household;
  • Parents, caretaker relatives, and foster parents; or
  • Caregivers of a family member who is enrolled in the Arizona Long Term Care System

A subsequent letter from the AHCCCS Administrator suggested that they (AHCCCS) are suspending their request for a 5-year limitation on lifetime benefits (for some members) for now.  Here’s our letter from back in February of 2017. 

 

Kaiser Family Foundation Issue Brief on Work Medicaid Requirements

Last month the Kaiser Family Foundation published an Issue Brief regarding CMS’ recent decisions to grant states the ability to experiment with their Medicaid programs that condition Medicaid eligibility on work or community engagement. The Issue Brief examines evidence of the effects of the Medicaid expansion and some changes being implemented through waivers.

Many of the findings on the effects of expansion are drawn from the 202 studies included in our comprehensive literature review that includes additional citations on coverage, access, and economic effects of the Medicaid expansion.

Regarding work requirements, the Brief concludes that “state-specific studies in Colorado, Kentucky, Michigan, Pennsylvania and most recently Montana and Louisiana have documented or predicted significant job growth resulting from expansion. No studies have found negative effects of expansion on employment or employee behavior. In an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment, and over half of expansion enrollees who were employed reported that Medicaid enrollment made it easier to continue working.  Another study found an association between Medicaid expansion and increased volunteer work in expansion states.

Furthermore, “work requirements have implications for all populations covered under these demonstrations. Those who are already working will need to successfully document and verify their compliance and those who qualify for an exemption also must successfully document and verify their exempt status, as often as monthly. States would incur costs to pay for the staff and systems to track work verification and exemptions.”

If you’re interested in the public health policy implications of our upcoming work/community engagement and reporting requirements, the KFF Issue Brief is a must-read.

 

Court Challenge to Kentucky’s Work Requirements being Heard this Week

Oral arguments are being heard this week in DC challenging Kentucky’s requirements that members work or participate in “community engagement” activities such as job training, school or volunteering. The case was filed in January by the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center.  The outcome could have implications for AZ’s upcoming requirements.

Read National Health Law Program’s guide on what to expect from oral argument.

American Medical Association Endorses Assault Weapon Ban

The American Medical Association – Nation’s largest physician group – endorsed a ban on assault weapons as part of a package of measures aimed at combating the epidemic of gun violence in the US. The member driven initiative was endorsed at their annual policy conference. They also endorsed a ban on bump stocks, which basically turn semi-automatic rifles into automatic weapons. 

In a statement AMA Immediate Past President David O. Barbe, MD, MHA said: “People are dying of gun violence in our homes, churches, schools, on street corners and at public gatherings, and it’s important that lawmakers, policy leaders and advocates on all sides seek common ground to address this public health crisis, in emergency rooms across the country, the carnage of gun violence has become a too routine experience.”

 

AzPHA Public Health Policy Update

Save the date

90th annual azpha fall conference and annual meeting

Integrating Care to Improve Public Health Outcomes:

Primary Care | Behavioral Health | Public Health

October 3, 2018 

Desert Willow Conference Center

There’s widespread support for the goals of the Triple Aim: To deliver the highest quality care with an optimal care experience at the lowest appropriate cost. The key is developing systems of care that best achieve these goals. 

Our 90th Annual Fall Conference and Annual Meeting Integrating Care to Improve Public Health Outcomes: Primary Care | Behavioral Health | Public Health will explore efforts currently underway to integrate care and improve outcomes in Arizona as well as initiatives on the horizon to develop systems of care that best achieve the goals of the Triple Aim.

We’ll kick off our Conference with a presentation of the latest academic research that evaluates the outcomes of co-located and integrated models of behavioral care as part of primary care as well as evidence-based toolkits to assist practices including ways to measure progress. We’ll also be exploring how providers are implementing new strategies to integrate care via AHCCCS’ “Targeted Investment” program which provides financial incentives to eligible providers to develop systems for integrated care.

We’ll conduct a short AzPHA Annual Meeting over a delicious buffet lunch followed by our keynote address from the American Public Health Association President Joseph Telfair, DRPH, MSW, MPH.  In our afternoon sessions, we’ll learn about new initiatives to work with managed care in two key areas that impact health outcomes: tobacco use and housing and homelessness.

We’ll close with a panel discussion of key leaders among Arizona’s Managed Care Organizations as they discuss priorities and strategies for improving outcomes under the new integrated Medicaid contracts which will begin October 1, 2018.  The new contracts will require better coordination between providers which can mean better health outcomes for members.

After the conference we’ll have a hosted reception as we celebrate AzPHA’s 90th Anniversary!

I’m still working on the agenda, but I expect to have it fleshed out in a couple of weeks and have our registration site up and sponsorship packets out by the 3rd week in June. A summary of the conference is up on our homepage at www.azpha.org.

 

American Cancer Society Changes Colon Cancer Screening Recommendation

The American Cancer Society changed their recommendation for colon cancer screening by moving down the standard recommendation 5 years- suggesting that most people get screened at age 45. There are a couple of ways people can get screened, either using a sensitive test that looks for signs of cancer in a person’s stool or with an exam that looks at the colon and rectum (a colonoscopy).  The reason they changed the recommendation is because new data shows that cases of colorectal cancer for people under age 55 increased 50% between in the last 20 years (1994-2014).

However, just because the recommendation from the ACS changed doesn’t necessarily mean that insurers will begin paying for it between 45 and 49 years old.  For that to happen, the United States Preventive Services Task Force would need to recommend the change and list it as a Category A or B preventive health service.

In recent years, a prevention model of health has woven its way into the fabric of traditional models of care. With the passage of the Affordable Care Act the role preventive services has expanded significantly in the US health care delivery system.  Preventive health care services prevent diseases and illnesses from happening in the first place rather than treating them after they happen.

Category A & B” preventive services recommended by the United States Preventive Services Task Force  are now included (at no cost to consumers) in all Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans have included Category A & B preventive services in the health insurance plans they offer to their respective members.

Currently, the United States Preventive Services Task Force recommends 49 Category A & B Preventive Health Services that include screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children.  The Task Force consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

You can also browse the USPHS website and check out the preventive services that they have evaluated but don’t recommend. Most of the services are broken down by age, gender and other risk factors.

 

Medicaid Program Scorecard Released by Feds

The Centers for Medicare & Medicaid Services released a new Medicaid program scorecard this week.  It includes some quality metrics along with federally reported measures in a Scorecard format.

The data that’s built into the state by state scorecard only uses information that states voluntarily submit.  There are 3 main categories (state health system performance; state administrative accountability; and federal administrative accountability) and lots of subcategories.

The most interesting part of the Scorecard I think are the State Health System Performance Measures portion.  Some of the subcategories that are reported in that category on a state by state basis are things like well child visits, mental health conditions, children’s preventive dental services and vaccination rates, and other chronic health conditions.

It looks like a good and valuable tool that will (if they continue to populate the scorecard) provide more transparency into the effectiveness of state Medicaid programs over time. The data that are submitted are voluntary – not compulsory – so that hurts the number of measures that states turn in.  It might be something that you’ll want to bookmark for reference in the future.

 

Federal “Right to Try” Law Passed and Signed

Congress passed and the President signed a new law this week that gives people with a terminal illness new options for treatment by allowing those folks a way to independently seek drugs that are still experimental and not fully approved by the US Food and Drug Administration.

The new law basically gives terminally ill patients the right to seek drug treatments that remain in clinical trials and “have passed Phase 1 of the FDA’s but haven’t been fully approved by the FDA.  

Arizona voters have already approved a similar law (by a wide margin).  In 2014 AZ voters approved Proposition 303  (referred to the ballot by the Legislature) that makes investigational drugs, biological products or devices available to eligible terminally ill patients. The AZ law has uses the same definition of an “investigational” drug that the new federal law uses.

 

Western Region Public Health Training Center Grant Renewed

The Western Region Public Health Training Center was awarded a renewed grant as a center for the Regional Public Health Training Centers Program.  They’ll continue to be housed in the University of Arizona Mel and Enid Zuckerman College of Public Health and we will continue to assess the training needs and strengthen the skills of the public health workforce with their partners in Arizona, California, Hawaii, Nevada, and the Pacific Islands.

The training center has literally hundreds of trainings that focus on all sorts of health professionals and the public health workforce.  So no matter what your public health workforce training needs are – the thing to do first is to check the centers website to see if they have the course that you need.  Most likely they will.

________

I’m doing my best to populate the “upcoming events” part of our AzPHA website.  If you have an upcoming public health related event- please let me know and I’ll get it up on our website at: https://azpha.org/upcoming-events/

Travelogue #8 Travel Tips & Break-ins

Since I’m claiming this to be a “travelogue,” I thought I’d offer some actual travel tips that I’ve picked up along the way.
 
Pictures are great, but hang on to your phone/camera (see part 7).
 
Booking discount airfare is great, but you might make sure that the airline uses actual plane parts assembled by actual mechanics.  This is a photo of my exit-row window seat on our flight from Amsterdam to London.  A wiser man might have disembarked, but hey, the flight was cheap.

Don’t let your phone run out of battery.  When your traveling pack of old farts finally gives out due to feet or knees or backs or some other failing body part, it’s not a good thing to have no way to summon an Uber or call a cab.

Don’t trust the weather forecast.  Every few hours, the forecast for the next few hours here shifts.  In the morning, it says it will be dry and partly cloudy that afternoon.  By 2:00, it is pouring on you, exactly as predicted when they revised the forecast an hour earlier.  I have decided that Arizona meteorologists are far superior to their British counterparts.  Here, they are rarely accurate more than a day in advance.  Back home, you can confidently depend upon the 10 day forecast when they say, “110 and sunny, 110 and sunny, 110 and sunny…”
 
While living for an extended period abroad, have all the tools you’ll need.  While cooking one evening, a can of tomatoes required opening, but all we had was a dysfunctional can opener.  Our friend Denise decided to attack the can with the small ax that we used for firewood.  Failing in this effort, she approached a neighbor, whom she had not yet met, ax still in hand, gesturing her inability to whack the can open.
 
The approach of a wild-eyed stranger waving an ax caused some alarm.  Perhaps that assisted with the prompt production of a can opener for our use.  We’ll return it without bearing arms.
 
For those of you who may have considered the traveling RV lifestyle, here’s an alternative.  Canals are plentiful in this part of the world.  Not just in Amsterdam and Paris, but even here in the English countryside.  This pic is just a few miles from my house and canal boats are both moored and traveling all the way up and down.  The tow paths make for great walks, too.  Meanwhile, I haven’t seen a single RV, no doubt due to the impossibility of navigating British roads in one of those behemoths.
 
Speaking of walks, once you figure out routes, you can seemingly get anywhere around here on foot.  The only thing keeping me from getting all my steps in on a daily basis is the weather.  But walking has its hazards as well, including hungry horses, angry cows (I thought Mad Cow was over with), poop of various sources, and the frequent “fork in the road,” which everyone from Robert Frost to Yogi Berra urges us to take, yet can send you far afield when you have no idea where you are to begin with.  On the other hand, that’s how I’ve discovered some of my most cherished sights.
 
When traveling, try to not be an ugly American.  One hears plenty of American accents in London and elsewhere that we’ve been.  In a lovely restaurant in Paris, we sat next to a young American graduate student and his parents, who had come to visit him.  He was such a know-it-all jerk to them, dismissing everything that they had to say and taking every opportunity to show off his knowledge of… well, everything, that I just wanted to smack him.  At another sidewalk cafe in Paris we sat next to a guy in a LA Dodgers cap going off on how the French had barely discovered kale, and were still eating couscous, while of course the newest thing in California was spelt.

Be prepared to walk.

Nowhere I’ve been on this trip has heard of the ADA.  Few mass transit stops are accessible without the use of stairs.  One exception in London offers an elevator – with a long line waiting – and a sign that warns that the number of stairs are the equivalent of a 15 story building.

As we found in Paris, when you’ve finished hiking to your platform, there is at least ample seating while you await your train.
 
Another piece of travel advice:  If your instructions for an AirBnB rental seem odd, consider renting elsewhere.
 
Nancy and I rented a lovely apartment in Paris for our time there.  It was sweet, as our communication was with the young woman who owned it.  Yet this was the only such rental I’ve experienced where you never see anyone.  We were to obtain the keys from the cafe downstairs where they had been left for us in an envelope, and drop the keys back in the owners mailbox upon our departure.  It all went smoothly, and we even replenished the coffee supply and tidied up considerably before we left.
 
Several days later, we got an email from this young woman that she had finally returned to her apartment to find it ransacked, with all her valuables missing.  The keys were not in her inbox, she claimed, and because there had been no forced entry, her insurance would cover none of it.  (Really?)  A few email exchanges later, and she said that AirBnB had suggested their “arbitration” services to negotiate claims for damages against us.
 
I still don’t think we’re being scammed, exactly.  She seems genuine and we haven’t heard anything more for several days, but I’m hoping that this doesn’t end up becoming a legal issue.  And next time, I’m only renting when there’s someone there to receive the keys and check us out, as has been my previous experience.  Lesson learned.
 
While Bobbie and Jack were here, I discovered that I had never regaled them with one of my more infamous travel stories.  Of course, I was compelled to share it with them.  I’m sure that some of you have heard this one before, so with apologies I include it here because, well, it is travel-related.  And because I told it again while here.  And because I’ve never actually written it down.  So here goes.
 
By way of background, several years ago I had a chronic TMJ issue.  That’s “Temporomandibular Joint,” as in your jaw.  It’s a classic joint to have problems, sometimes requiring surgical intervention.
 
I never had much pain with it, but I developed a “click” in my left jaw when I sometimes tried to open my mouth, which progressed to greater and greater resistance over time.  Finally, I would occasionally find myself unable to open my mouth at all, my jaw clenched, until I managed to dislodge it.  At first, dislodging it required strenuously forcing my mouth open, culminating with a loud “pop” that could be heard across a room.  But as time went on, I found that I could only force it open by whacking the side of my jaw with my hand.  Hard.  Sometimes several times.  Hard.
 
Needless to say, when this occurred in a public place, others in my presence might be disturbed by the sight of the crazy man quite literally punching himself repeatedly in the face.  In general, they avoided eye contact and shuffled off.
 
Throughout all of this progression, I practiced the tried-and-true medical strategy of ignoring the problem.  I mean, it didn’t really hurt, and it only happened once every few weeks or so.  I only occasionally freaked out passersby.  And I really didn’t want to hear what course of treatment might be recommended.
 
Once during this same period, I also had the misfortune to scratch a cornea.  If you’ve never had that happen, think OWIE.  Big OWIE.  It hurts in a unique way.
 
To allow the cornea to heal, you need to minimize the amount of rubbing of the inside of the eyelid against the eye.  In years past, they would try patching the eye, until that was shown to be pretty worthless.  Now they just instruct the patient to keep that eye closed, and to try to not move your eye around.  Look left and right by moving your neck, not your eyeball.  The pain encountered by moving your eye provides instant feedback to help remind you.
 
A couple of days after scratching that cornea, I had to take a flight for a meeting.  I passed through the airport and boarded the plane keeping my one eye closed, hoping not to look too weird, and settled into my aisle seat, with an empty middle seat between me and and a passenger in the window.  As I often do on flights, I quickly fell asleep.
 
Sometime later I was awakened by the conversation between a flight attendant and my aforementioned fellow passenger.  As I stirred, I realized that in my slumber, I had leaned upon my arm so that it was now completely asleep.  Numb and flaccid.  My face had also been firmly planted in such a way that I could tell it was a droopy, wrinkled mess.  And to my chagrin, as I regained consciousness, I also realized that my TMJ had kicked in and my jaw was locked.
 
There I sat, one eye closed, one side of my face drooped, with a totally flaccid arm and a clenched jaw.  I was a textbook picture of someone who had just had a stroke.  The flight attendant eyed me with alarm.  “Sir,” she inquired, “are you alright?”
 
“Arrrawagggh,” I replied, unable to open my mouth to speak.
 
The flight attendant spun on her heels and hurtled up through the aisle.  I glanced at my seat mate to my right just long enough to see that she had pushed herself up against the wall of the plane, recoiling in horror.  Probably not a good time to begin socking myself in the jaw to relieve my condition, I thought.  In no time I spied the flight attendant rushing back in my direction with her flight attendant buddy in tow.  And I had a sickening premonition that I was about to hear that dreaded overhead page, “Is there a doctor on board?” In response to which, of course, I would be ethically obliged to raise my one remaining good arm and shout, “ARRRAWAGGGH!”
 
And one final piece of travel advice:  take all your keys with you when you leave your rental property.
 
We took our buddy Denise into London on a day that we knew a realtor was going to be showing the cottage to future potential renters.  It was Denise’s last day here, as she was flying out the next morning.  We had a good time.  We ate lunch at our favorite place (the best seafood restaurant on earth, I’m convinced).  We caught a show (“Everyone’s Talking About Jamie”).  We ate dinner at a fav pub.  We took a train, taxi, and another train on our return.  We didn’t arrive home until nearly 11 pm.  It was just starting to rain.
 
Nancy stuck her key into the door lock and turned it, but the door didn’t budge.  It was being held shut, as if by a separate deadbolt.  It took a moment to realize that the second lock on the door, which had an old-fashioned skeleton keyhole and which we had always ignored, was locked tight.  Previously, I hadn’t even thought it was functional.  It seemed so antiquated, so merely decorative, and I didn’t think there was even a key to it, as we didn’t have one.  (It turns out that, unbeknownst to me, there actually was a set of keys inside.)
 
Obviously, the realtor did have a copy of that key.  And had used it.
 
We checked the back door.  It was locked, but we knew it was a flimsy latch that we could kick if we had to.  I tried both of the ground floor windows.  Shut tight.
 
Lots of options sprung to mind.  There was an open window on the second floor, but no easy way to reach it without depending upon a rickety-appearing overhang for support.  I searched for a ladder behind a neighbor’s home that I had seen days earlier, but couldn’t find it.  Might a neighbor have a spare key?  All their lights were off, save those in the elderly lady’s house whom I knew by reputation would call the police for any suspicious activity.  Nancy had the landlady’s number in her phone, but her phone had earlier run out of juice (see above advice), so we found ourselves back sitting in the running car to charge her battery.  But that wasn’t the solution, as we needed our home WiFi to call anyone, because we’re out of cell range out here in the sticks.
 
At this point, with Nancy seriously suggesting kicking the back door in, the better part of valor might have been to seek out a hotel in some nearby town.   But Denise needed to depart for the airport in the morning, all her stuff was inside, and there were no better prospects of getting the landlady or the realtor out early the next day – the Sunday of a three-day weekend – than there was of doing so that night.
 
In desperation, as Nancy sent texts from the car, I went to the pub, which was just in the process of closing up, but had plenty of folk still gathered on this Saturday night.
 
Did they know our landlady well enough to have a spare key?  No.  Did anyone have a ladder that could reach our second-floor window?  No.  I borrowed their phone, but didn’t get through to our landlady and couldn’t leave a message.
 
One young patron with whom we’d shared some prior lively conversation perked up.  “Let me have a look,” he said, and followed me home to investigate the possibilities.  As he staggered around our property, I discouraged him from his thoughts of trying to climb the wall to the open window.
 
I returned to the pub intending to try calling again.  A few young, inebriated lads passed me on their way toward our cottage, insisting that they’d “broken into plenty of houses before.”  Meanwhile, in my brief absence from the pub, our landlady had returned the missed call from the pub’s phone, spoke to others there, so now had an inkling of an idea of the drama that was consuming her property.  I finally got through and spoke to her and she said she’d try calling the property agent, as they refer to realtors here, although she wasn’t sure whether they even had an emergency contact number.
 
I rushed back to the scene of the crime that was now our cottage to find our inebriated young friend quite literally shoving another inebriated young man up off his shoulders towards the second floor window.  The would-be burglar was grasping for whatever toe-hold he might find along the brick wall below the open window which, I was pretty sure, would not support much weight.  And of course, all of this was in the rain.
 
I severely protested, humbly suggesting that they not break their necks in this endeavor.  Every injury prevention synapse I possessed was firing warnings as I watched in alarm this wobbling tower of amused determination.  One foot was perched upon a shoulder, the other upon the palm of an outstretched arm, straining to push upwards toward the promise of a flimsy window pane just beyond reach.

“They’ll be fine” insisted an onlooking third inebriant, as legs and arms flailed about the brick wall.  I flashed on Will’s old blog describing his sudden descent from a tree.

 
It worked.  In no time, he scooted through our window, descended the stairs, and opened our door.
 
I owe these guys so much beer the next time I see them in the pub.  And the time after that.  And perhaps the time after that.  And I believe them that they’ve broken into plenty of houses before.
 

 

Travelogue #7: “The Number You Have Called is No Longer in Service”

Nancy and I went to Paris for a few days.  A great experience full of interesting sights and spectacular food.  And it had an interesting start.

The first night we were there, we hooked up with a friend (who is house sitting for us) and her boyfriend.  To protect the innocent, they shall remain nameless.  We were to meet for dinner at a restaurant that had been recommended to them.

We arrived at the arranged spot, and found them already in line at the crowded, obviously popular establishment, only to then be told that there were no tables for four all night.  Hmmm.  The place doesn’t accept reservations.  There were perhaps four hours to go before it closed.  It was enormous.  No tables for the duration?  Perhaps they had seen me coming.

In any case, a quick search found a restaurant just next door with a table immediately available.  We settled in without any idea where we were, until we were presented menus that made it clear.  Burgers, tacos.
 
We were in one of the few restaurants in Paris with an exclusively, to the point of being mocking, American menu.

So my first ever night in Paris, perhaps the culinary capital of the world, I had fish tacos.  Battered, fried fish.  With mayo.  Yum.  But the company was great, we had a great time, and all was well.

It was the only bad meal I had there.  It appears that the key to delicious cooking is butter.  Lots of it.  I don’t understand how it is that the entire population of France doesn’t die of coronaries at the age of 40, but they don’t.  I must consult my former nutritionist staff upon my return. 

We saw amazing things there.  For example, there was this enormous movie set that apparently was built for the movie, “Hugo.”  It was in the design of a large railway station.  After the filming of the movie, they apparently didn’t know what to do with the set, so they filled it full of old stuff like pieces of canvas with paint on them.  My favorites were those signed by Vincent somebody.  But the best part was the food in the cafe.  Now THAT is art!

While we were there in Paris, we hopped on a giant Ferris wheel on the Allee Centrale, near the Louvre.  Another photo opportunity from aloft on a day already packed with photos.  Nancy and I both whipped out our phones to snap pics.  I duly cautioned her to hang onto her phone as she sat next to the door which had an open space around it.

Now, you know that when you’re taking pictures through glass, it often helps to press your phone up against the glass to reduce glare.  I swiveled in my seat and pressed my phone against the glass behind me as we gracefully rose high into the sky.

And yes, of course I let it slip.  Rats, I thought to myself, now I’ll have to fish it out from behind the back of the seat.  I twisted, peered, and realized that there was no “back of the seat.”  I was looking at open air, with steel beams supporting our carriage some 30-50 feet directly below, and pavement an equal distance below that.  No phone in sight.

If you’ve ever been in a traffic accident, you know the feeling “no, this isn’t happening,” immediately followed by “no, this didn’t just happen.”  Suddenly, the beautiful view was lost on me, as we slowly circled around and around, and all I found myself doing was peering straight down for any sign of splattered electronics, to no avail.

When they let us out, I instantly bolted for the area into which it would have fallen — nothing.  I sprinted from one worker to another to another, each responding with, “You did what?”  I was referred elsewhere and then elsewhere until at my last chance someone stepped from behind the befuddled employee who didn’t quite understand me, and held out my phone.

It was intact.  I mean, the glass wasn’t even cracked.  An obvious yet minor scratch on one corner of the protective case, covered by a small bloodstain and a tuft of hair wedged between the case and the phone.

OK, so I’m kidding about that last part.  But I’m fortunate that I hadn’t actually beaned a stray passerby or I’d be writing instead about the workings of the French criminal justice system.

Despite the intact appearance, the phone was well and truly dead.  My attempts at CPR were useless.  I had killed it.

Days later, back in the UK, I trekked to the closest Apple store where they confirmed the irreparable demise.  We’ve paid for coverage that includes clumsy klutz damage, although we shall soon see whether that includes tossing the phone from hundreds of feet.  Perhaps those of my colleagues who work on the 14th floor of my former office will benefit from the results of my inquiry, as I’m sure I wasn’t the only one tempted from time to time to pitch my phone out the window.

So the same day that the “Genius Bar” staff pronounced my phone DOA, I went to the giant Tesco supermarket nearby and got a cheap, temporary replacement, so that my same phone number could be used by transferring the British SIM card we had previously bought, and importantly, to make it possible to connect with others whom I had ditched earlier that day and needed to travel home with. 

I proudly took my new phone and began texting.  None went through.  So I began calling.  None went through.  No problem, I thought, I had brought my tablet as a backup, and I knew that texts and at least email went through with that.  Halfway through typing my first message, it stopped working.  I mean, it would no longer respond to anything I did.  I couldn’t even turn the thing off because it wouldn’t respond to my touching the screen where it said, “swipe to turn off.”

Sheepishly, I walked back to the Apple store.  As I presented my tablet to a young man whom I swear I hadn’t seen earlier in the day, he greeted me with, “Oh, you’re the guy who dropped his phone from a Ferris wheel!”

I have achieved infamy on both sides of the Atlantic.

As I scribble this, sitting in a coffee shop in Watford (a city with which I am becoming much more familiar as I walk back and forth repeatedly between the same shops), I have no idea how on earth I’m reconnecting with anyone today, nor exactly how I’ll get home.  If you receive this, you’ll know that I survived… somehow… yet again.

 -Bob

Travelogue #6 The Traveling Old Farts

The traveling old farts:

Our buds Bobbie and Jack came for a visit.  We all went to Amsterdam, taking the train from London.  It boggles my mind that one can take a train under the English Channel, zip along at ~200 mph and arrive in Amsterdam a few hours later.  We traveled late, and found our way to our AirBnB rental near midnight.  Having not eaten dinner, and being totally unfamiliar with local eateries, we sought sustenance from the bar immediately beneath our apartment.

There were still a few patrons, and a lovely young French woman served us.  Unfortunately, she spoke little English, and interestingly, little Dutch as she attempted to communicate our questions to the bartender/cook.  Thankfully, our confusion was minimized by the fact that there was almost nothing left to eat.  Yes, there was still food, it turned out, but only “snacks.”  We perused the appetizer menu until we were later informed that by “snacks,” they meant only nachos.

So in desperation, we ordered the nachos.  We were presented with tortilla chips covered with some sort of melted Dutch cheese — so far, so good — but with a “salsa” consisting of three large, round slices of tomato on top and scattered green cocktail olives.  Hmmm.

We devoured them.

As you may recall, I had earlier complained about the configuration of the stairs in our English cottage.  No more.  Not after having lived through climbing two flights of “stairs” to our apartment in Amsterdam.  Think: even narrower, even higher angle of elevation, and perhaps 4 inches in depth in places.  A rope ladder would have felt as secure, especially with luggage in tow.

he Netherlands is, however, incredibly lovely, both physically and in spirit.  Bikes are everywhere, actually outnumbering cars it seems, with their own lanes and traffic lights.  Being a pedestrian is rendered a bit more hazardous by this, although having a cheery bicycle chime alert one to the fact that you’ve just errantly stepped into their path is considerably less disconcerting than having a car horn blast away at you in New York.

Just a few blocks from where we stayed was a magnificent granite gateway, soaring several stories high in the air, with an inscription in Latin which, I at first presumed, carried some profound or historic message. 

Then I read it.

“HOMO SAPIENS NON URINAT IN VENTUM” it proclaimed majestically.  OK, I thought to myself, “Homo sapiens” I know.  “Non” seems obvious.  “Urinat?” Um… I think I understand, although I’ve never seen it so dramatically written.  “In” seems universally to mean, “in.”  “Ventum” I had to look up.  It means, “wind.”

Really?  A monumental structure devoted to warning all who may pass, “People, don’t piss into the wind!”  Really?  There’s a story there that I might look up, but it’s probably better to not.

Just outside of Amsterdam, we went to the Keukenhof tulip festival.  It was beautiful, but reinforced a fear in me that I may spend the rest of my life merely gazing at lovely things, if not my navel (which is, I assure you, not so lovely). 

You see, I confess that this retirement thing still hasn’t sunk in.  Max told me before I left that it would take me a month just to decompress.  Well it’s been a few, and I’m still discombobulated. 

It took that first month for my usual dreams to switch from the work-themed panic-stricken variety (forgetting to pack for a trip, forgetting a to give a talk, etc) into those less stressful. Now, I even occasionally wake from a dream in which I miss being part of the action.  I also do so occasionally when awake.  Occasionally, I stress.  🙂

Speaking of stress, there are other ways to achieve it, such as watching news from an international perspective.  There is every imaginable channel here.  Want news from India?  China?  There’s even “local” channels in other languages, such as Welsh, where you can watch football matches and such with a commentary understood only by people just a little to the west of us, and nowhere else. 

There are also truly disturbing outlets available.  Salisbury, where the former Russian spy and his daughter were poisoned with an unimaginably potent nerve agent, isn’t very far from here.  As you might imagine, that evolving story and the saber rattling that resulted was even more prevalent on the news here than I imagine it was back home.  But a channel I can watch here that I never could at home is something called “RT,” which is “Russian TV.”  It’s actual English language Russian government-sponsored news. 

OK, at home we may decry the ideological bias in Fox News or MSNBC, but nothing compares to real, true government propaganda.  It is amazing to watch.

The poisoning never happened.  Then it did, but it was obviously the Brits who did it, then it wasn’t the same poison after all, on and on.  But then, in the midst of this, when the US missile attack on Syria was looming over another alleged (but RT-denied) use of chemical weapons, I watched as show after show declared, “If Trump gets his way and there is World War III…,” or ended their broadcasts with, “We only hope we’re all still here for next week’s show.” 

AAAUGH!
 
This channel with Russian government-approved news was actually preparing their surviving viewers for who to blame when the inevitable Armageddon occurred within a few days.  Like anyone would care whose fault it was.  Like anyone would care that anyone else would care.

I grew up in the “duck and cover” generation.  If you’re too young to know what I’m talking about, you’ve avoided a lifetime haunted by memories of a childhood spent practicing for nuclear annihilation as casually as practicing fire drills.  Hear the recess bell sound repeated short bursts?  Line up single file to walk calmly to the playground to await the fire trucks.  Hear the recess bell in one, long tone?  Crawl under your desk, turn your little butt to the glass windows, and await either instant vaporization or a blast that will send thousands of glass shards into those little butts.  Only much later did it occur to us that radiation poisoning would take us before those little butts ever had a chance to heal.

To watch a state-sponsored media outlet broadcast messages seemingly in anticipation of the real thing felt just a wee bit disconcerting. 

I have stopped watching RT.

We also spent time with Bobbie and Jack in London, of course.  On one such trip, we bit off more than we could chew, and after walking more than a few miles, we resembled the walking dead.  Between the four of us, we included two asthmatics, one diabetic, and four old farts.  With aching backs, sore feet, asthma, failing knees, blood sugar swings, and general poopiness, we were quite the sight as we staggered through ancient London streets and dodged young joggers who were oblivious to their surroundings.

I must say, if you plan on walking in London, be prepared to dodge joggers at least every minute or so.  They are plentiful and despite the risk they pose to mere pedestrians, it is a beautiful thing to see so many Brits committed to taking care of themselves. 

Update on the remainder of our schedule:

Denise is here visiting us until May 27.
We may be gone from ~June 1 until ~June 12, seeing a friend of Nan’s in Germany, visiting Vjollca in Kosovo (yea!), and perhaps another friend in Romania, if it all works out.

Ron is here June 14 until June 26.
We travel to Finland to meet Dawn and Anthony at his conference June 26 until July 1.
July 1 until July 8 we are at Lake Como in Italy with family.
For a few days after that, hopefully in other places in Italy.
By July 13 at the latest, back in the cottage in Belsize, England.
July 18-29 Dawn and Anthony are back here, and we all close up the house.
Departure on July 29 either home or to one last fling somewhere before heading home to the US.

Can we time it or what?  Returning to Phoenix in late July or early August.  We will know we’re home the moment we step off the plane!

It seems like a lot, but changes may occur, and please let us know if anyone thinks they might be heading to this part of the world before we return.  We’re having a great time hosting, and you can’t beat free rent in Europe.

‘See y’all soon.

-Bob