Articles

Photobook: Shutterfly vs. Printique (no contest)

Last post I noted the bird photobooks I was putting together. I had originally put one together in the summer on Shorebirds, and then backed off doing more until the last month or so. For the first one, I saw a coupon for Shutterfly and used them to produce a lay-flat photobook.

It looked fine, and the photo quality was…ok. Nothing more. Before deciding to do a whole series, I poked around and looked for reviews of other places, and thought I’d try Printique. The first of the those arrived today, and suffice it to say I’ll be using Printique for the rest of the series.

Deep, rich blacks. Beautiful color prints. And the thickness of the lay flat pages is unbelievably thick and durable. The Printique book is about twice as thick as the Shutterfly book despite having similar number of pages. Cost? The Printique one was a touch more, but not much. General costs:

  • Shutterfly – 38 pages, 10×10″ lay-flat – $93.49 total cost
  • Printique – 42 pages, 10×10″ lay-flat – $107.17 total cost.

`$14 more, for 4 more pages, but vastly improved stock thickness and photo quality. I also preferred the tools for developing the photobook on Printique.

Just my observations on using the two! I’m not in contact with either company or being compensated here! Just some friendly advice if you’re looking for a really high quality photobook to display your photos.

Comparison of thickness of the two books! Astoundingly better quality of page stock for Printique with very thick durable lay-flat paper.
Final photobook for “North American Waterfowl” by Printique.

Why “Alex” > “Olivia” > “Nate” — Health care in America

Three Happy Children

Three happy children, “Alex’, “Olivia”, and “Nate”, living in a world where Alex will receive better health care than Olivia, and Nate will receive the worst health care of all 3, all because of their socioeconomic status.

We’re two weeks into a new Congress that smells blood in the water.  Other than a flurry of legislation designed to limit transparency and ethics oversight (always a great sign when that’s their first thought when they arrive in Washington), the major focus has been the dismantlement of Obamacare (the Affordable Care Act, ACA).  What is abundantly clear is that those voting to “repeal and replace” the ACA, without having ANY idea of what they might eventually replace it with, are oblivious to the impacts of the law on real Americans.  What follows is a NOT so hypothetical story of three children, “Alex”, “Olivia”, and “Nate”, and what health care policy in the United States means to them.

Alex, Olivia, and Nate are all young teenagers or pre-teens.  Each has Type-1 diabetes, the auto-immune version where their own misguided immune system has attacked and destroyed the islet cells in their pancreas’ that make insulin.  For the rest of their lives, they will be dependent upon insulin injections.  It’s a life fraught with risk. If you don’t control your blood sugars well, you’ll have frequent hyperglycemia events (high blood sugar). Over time, that will contribute to kidney disease, eye disease, cardio-pulmonary disease, and peripheral nerve damage. If you’re extremely vigilant and try to control your blood sugars very tightly, you’re more likely to have hypoglycemic events (low blood sugar), a dangerous condition that can cause seizure, coma, and even death.  Long-term blood sugar control is measured with a patient’s “A1C”, a hemoglobin-based measure from your blood.  A “normal” A1C is less than 6.5. The higher a diabetic’s A1C is, the worse their long-term blood sugar control, and the higher their risk for complications.

There’s little doubt the ACA is a god-send to Type-1 diabetics like these Alex, Olivia, and Nate.  No longer can they be refused insurance coverage for their pre-existing condition.  Diabetes is an expensive, life-long disease, but thanks to the ACA, they will no longer be subject to lifetime maximum payouts from insurance companies.  For parents helping them transition to an adult life and the responsibility for their own health insurance, the ACA allows parents to cover children on their insurance until they turn 26.  Things are much better with the ACA, but even with the ACA, we’ve got a long way to go in providing equitable health care in the United States.  With that as background, here is the not-so-hypothetical story of Alex, Olivia, and Nate and their battle with Type-1 diabetes…and the American health care system.

“Alex”

Alex is a young teenager who was diagnosed with Type-1 diabetes at a very young age.  His family would be considered  upper-middle class. Alex’s family has a very good, comprehensive health care plan, with insurance provided through one of Alex’s parents. Alex has had access to some of the best care a young diabetic can have. For over 10 years, Alex has had an insulin pump, a small device that holds a reservoir of insulin.  His pump automatically provides a steady stream of insulin all day long (the “basal” insulin), just as the body normally does, to try to keep blood sugars stable. His pump also makes it easy to administer insulin at meals.  He simply estimates how many carbs he’s eating, enters that number in the pump, and the pump provides the proper amount of insulin required to process the sugars in that meal. Alex checks his blood sugar very often (8-10 times a day), but was still occasionally experiencing both hyperglycemic and hypoglycemic events.  In addition to his pump, his family pursued a “continuous glucose sensor” (CGM), another medical device that automatically checks his blood sugars every 5 minutes.  The CGM even has a cell phone app, where his parents are alerted on their cell phones if his blood sugars need attention. He no longer faces the dangerous “nighttime lows”, a hypoglycemic event that may occur at night when a patient is asleep and less able to respond. If Alex’s blood sugars start to drop anywhere close to dangerous levels, an alarm will alert both him and his parents that action is needed.  Alex’s A1C levels have typically been right around 7.0, just a bit above that of a “normal” person.  With the new CGM, it’s likely that will go down even further.  Alex’s care is expensive.  The insulin pump and the CGM both costs thousands of dollars, as do the yearly supplies that support those devices.  Along with the costs of insulin, doctor visits each month, and other supplies, Alex’s health care costs without insurance would be in the 10s of thousands of dollars per year.  Even with what’s considered quite good insurance, his parents pay a lot out of pocket each year for the pump, CGM, and supplies. They can afford it, however, and Alex’s long-term prognosis and risk of complications is much lower than Olivia’s or Nate’s.

“Olivia”

Olivia is a pre-teen who has had diabetes for about 5 years.  Her family would be considered middle-class, perhaps lower middle class. Olivia’s family has a health care option through a parent’s employer, with coverage that isn’t nearly as good as what is provided by Alex’s insurance. Olivia’s family would like a better insurance plan, but their income is high enough that they’re not eligible for subsidies under the ACA that might enable them to “shop around” and find better insurance.  Olivia’s insurer covers only part of the costs of an insulin pump, and does not cover costs for a CGM.  Olivia’s family cannot afford the out-of-pocket costs that would be required to get an insulin pump, so Olivia does not have an insulin pump, or a CGM.  Her insulin control relies on frequent injections, with a daily “long-acting” insulin that is meant to mimic the basal insulin (the steady, day-long drip) provided by Alex’s pump, and “short-acting” insulin that is given with every meal.  Olivia doesn’t like needles, but as a young diabetic, she’s learned to tolerate them. Olivia knows Alex, and marvels at his pump, which frees Alex from the 4-6 daily injections that Olivia gets.  Olivia checks her blood sugar as frequently as Alex, 8-10 times per day, which helps keep her blood sugars under control.  She can respond when blood sugars are low or high, but it means another injection (for high blood sugars).  Without a CGM, she’s more subject to unnoticed hypoglycemic or hyperglycemic events.  Unlike Alex, who “feels” when his blood sugar is low, Olivia has no such physical feelings or warning signs when her blood sugars go low.  She recently was hospitalized after a severe, nighttime hypoglycemic event, when extremely low blood sugar results in seizure and a short period of unconciousness.  With her diligence in checking blood sugars, however, those events are minimized. Her A1C is significantly higher than Alex’s, usually around 8.0 to 8.5.  Compared to Alex, she’s thus not only at risk of unnoticed high or low blood sugar events, she’s also more likely to develop longer-term complications such as heart disease, kidney failure, or eye disease.

“Nate”

Nate is a teenager who was diagnosed with diabetes about 10 years ago.  He lives in a single-family home, a good home with a very loving mother, but paying the bills is a struggle.  The only health insurance available to Nate’s family prior to the ACA was a “catastrophic care” policy with very high deductibles and much poorer coverage than either Alex or Olivia receive.   After Nate was diagnosed, the economic struggles meant pinching pennies on health care. It even meant pinching pennies on the administration of insulin. At difficult times, Nate’s family would avoid carbohydrate-laden meals, in order to save money on the amount of insulin needed to treat Nate. Visits to the endocrinologist were few and far between, as Nate’s mother couldn’t afford them.  Nate’s blood sugar control was very poor prior to the ACA, with A1C’s typically over 10.  Under the ACA, subsidies are available, including both tax credits and cost sharing subsidies, that ensure a plan on the ACA marketplace can’t cost more than 9.5% of a family’s income. After the ACA, Nate’s mother enrolled in a marketplace plan and obtained a health care plan that was much better than the poor health care option provided through her employer.  However, Nate’s insurance is similar to Olivia’s, in that only partial costs of an insulin pump would be covered, and a CGM is not covered.  Nate’s mother cannot come close to paying the out-of-pocket costs that would be required for an insulin pump. Nate relies on shots much like Olivia does.  Nate’s mother is extremely thankful for the availability of ACA coverage, as without it, even the cost of insulin would have been very difficult for her to pay under her employer’s poor, catastrophic coverage insurance.  However, the family still struggles with everyday costs, including costs of health care. With the only available, affordable ACA plan, coverage is worse than either Olivia’s or Alex’s.  Nate’s situation has improved, but his family is still forced to make extremely difficult healthcare decisions, regarding both health care and other, every-day expenses.  With another sibling with asthma and other problems, covering health expenses is difficult even with the ACA and tax credits.  Visits to the doctor are fewer for Nate’s family than for Olivia’s and Alex’s. Blood sugar control has improved for Nate with the better insurance from the ACA, particularly as the family doesn’t feel the need to “scrimp” on insulin, yet Nate still has A1C levels that approach 10 at times.  Nate is at substantially higher risk of long-term complications than either Alex or Olivia.

Comparing Alex, Olivia, and Nate

Alex > Olivia > Nate.  That’s the situation in today’s health care system, where your level of care is directly related to your ability to pay.  With Type-1 diabetes, blood sugar control is LIFE.  There are tools available that assist a Type-1 diabetic in maintaining blood sugar control, but those tools are of no use if a family can’t afford them.

In all likelihood…Alex will outlive Olivia.  Olivia will outlive Nate.  It’s as simple as that, when blood sugar control is the key to a long, happy life for a diabetic.  Particularly a type-1.  It has NOTHING to do with the love of a family, or the desire to keep blood sugars under control.  The parents of Alex, Olivia, and Nate all love their children very much, and would do anything to keep them as healthy as possible.  It simply boils down to economics. Even if insurance provides some access to advanced treatment options, that’s useless if the family can’t afford co-payments or other fees required to get those advanced options.

The ACA is far from perfect, but also a much, much better situation than we had prior to the ACA. The ACA is a step in the right direction, but more is needed. Instead, we’re heading backwards.  The split between the “haves” and the “have nots” has never been more evident in the United States, and as the not-so-hypothetical case of Alex, Olivia, and Nate shows, that divide is also still clearly evident in how we dispense our health care.

A nerdy scientist’s assessment of risk – Tornadoes vs. Earthquakes

Tornado Risk map - Dakotas

Tornado risk map from the National Weather Service for July 17th, 2015. Sioux Falls was squarely within the 2% zone, meaning there was a 2% chance of a tornado being seen somewhere within 25 miles of your location. Somehow…we all survived.

While at a conference for work in Portland last week, my colleague and I had a nice supper with two USGS colleagues who work in Menlo Park, California and Seattle, Washington, respectively.  We had relayed the news that the night before, there was storm damage in the area, with straight line winds and tornadoes both causing damage.  The West Coast colleagues…oh…let’s just call them “Ben” and “Tamara”…were flabbergasted that we’d want to live in an area so prone to devastating storms.

Tonight, the National Weather Service put out the map I’m showing here, noting that parts of South Dakota had either a 5% or 2% chance of a tornado hitting somewhere within 25 miles of your location. Let’s do the math!  What are the odds of a tornado hitting YOUR exact location on a night like this, when tornadoes were indeed spotted?

An area with a radius of 25 miles is over 54 billion square feet of territory. What are the odds of a tornado hitting your bit of territory, with a 2% chance of one being seen somewhere in this area? The average tornado path is 4 miles, or 21,120 feet. Average width is 500 feet. The average damage path is 10.5 million square feet. Even if you’re in the highest probability area, 5% chance of one being seen relatively near, the chances of one hitting YOUR chunk of territory…0.0010%. For the 2% chance of a tornado near you, the odds are 0.0004% it will strike your exact location.

Without Warning - Oregon Cascadia earthquake Comic

An actual comic-like booklet put out by the Oregon Office of Emergency Management. Yes, West Coasters…you’re in imminent danger of being swallowed whole by a massive earthquake. Tornadoes in the Plains? They’re nothing in comparison.

Just a guess…but we probably have chances similar to this only like 4-5 times a year. If you just use the same strike probability assumptions, you thus only have, likely at absolute most, a 0.0050% chance of a tornado hitting your location in a given year.

That’s an average of about one hit on your exact location every 20,000 years. Most tornadoes are weak F0 or F1, so even a hit might not be that bad.

Now, let’s reconsider the situation for my colleagues living in California and Seattle.  This week the New Yorker ran a story about the upcoming massive Cascadia subduction zone earthquake that could hit, The story said on average, something similar to the massive 1700 earthquake thought to have hit the area occurs about once every 250 years.

Put it all together, and Seattle is 80X as likely to get walloped with a 9.0 earthquake as Sioux Falls is to get a direct hit from a tornado, and even a direct tornado hit in Sioux Falls is likely to be far, far, less damaging than any earthquake.

You are welcome, West Coast storm-haters.  I hope I have reassured you that is once again safe to visit us in stormy Sioux Falls.  🙂

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