Wednesday, December 23, 2009

Health Reform: The good, the bad, and the bigoted

The New York Times, in a December 22, 2009 editorial, calls the Senate bill “well worth passing” (A Bill Well Worth Passing), and says that it is “worthy of support from lawmakers who care about health care reform.” Whether it is worthy of support by the American people is another question entirely. The Times says that there is “…a lot to like in this bill”, and this is certainly true, as there are many parts of it, that include funding for many good programs. Some of the issues that I have written about in the past, such as primary care extension services and funding for primary care education (“Title VII”) are included in the bill. That makes me happy, and I think that they should be good for the health care of the American people.

A proposal that would expand graduate medical education funded by Medicare by 15,000 slots did not pass, which also makes me happy. Through aggressively supported by the Association of American Medical Colleges (AAMC), it has been opposed by family medicine organizations because the expansion would have been willy-nilly, not giving preference to or even a guaranteed base of funding for primary care. While it is true that there are needs for new physicians in areas other than in primary care, any bill that does not absolutely guarantee primary care slots will result in hospitals allocating them to those specialties that make the most money for the hospitals – certainly not primary care. Moreover, the key flaw of counting all students entering 3-year internal medicine residencies as primary care, despite, as I have discussed (recently November 17, 2009 Primary Care’s Image: A Problem?, October 14, 2009 "War on Specialists?": Wall St. Journal defends the status quo!, October 8, 2009 "Uncomplicated" Primary Care?), the fact that the vast majority of them will enter subspecialty fellowship training. There is an excellent Op-Ed on December 23, 2009, addressing this issue in the Times, "Doctors no one needs", by Shannon Brownlee and David Goodman.

What, of course, is less good (or, as we might say, “bad”) is that 1) it doesn’t cover everyone; 2) it will save some money, maybe, but only a small portion of what might be done by a public option, not to mention a single-payer plan; 3) it will make the insurance companies even richer; 4) it will not guarantee affordable health care for Americans. We have already discussed this (December 6, 2009 Health Care Needs Should Guide Health Reform). It has even eliminated the buy-in to Medicare for people over 55. The core problems with the bill are detailed in the letter to the Senators by the leadership of the Physicians for a National Health Program (

But, as the Times notes in its front-page article on the bill (Democrats Face Challenge in Merging Health Bills by Robert Pear and David M. Herzenhorn), “Democrats were grappling Monday with deep internal divisions over abortion, the issue that most complicates their drive to merge the Senate and House bills and send final legislation to President Obama.” And this is indeed the part of the Senate bill, and in the House bill’s Stupak amendment, that gives free rein to the bigots who feel, literally, that it is their God-given right to apply their moral compass to the most important life decisions of the rest of us. In trying to garner the votes of marginal Democrats (like Ben Nelson in the Senate), the Congress has bowed to the efforts of the Catholic bishops to try to not only control the lives of their own believers, but those not of their religion as well. Make no mistake about this. As much as opponents say that they are opposing abortion, what they are actually doing is choosing to make the decisions about it for other people. All of those people who are affected are women, and most of those making the decision – including all bishops – are men.

Trying to reach a compromise (New York Times, Negotiating to 60 Votes, Compromise by Compromise, by Robert Pear, December 20, 2009), the Senate came up with nonsense. “In what they described as an effort to reduce the demand for abortion, Democrats would provide money to help pregnant teenagers and new mothers so that they could stay in high school and attend college. The federal government would provide $25 million a year for a ‘pregnancy assistance fund.’ The money could be used for ‘maternity and baby clothing, baby food, baby furniture and similar items,’ the proposal says.” If they weren’t politicians, these people would be described as, using the technical term, “lunatics”.

If you really want to “reduce the demand for abortion”, the first step, the necessary step, the sine qua non, is to reduce unwanted pregnancies. Amazing idea! How would we do that? Well, one way would be to tell people, convince people, cajole people, pray for people, and bribe people not to have sex, or not have sex with people to whom they are not married, or not have sex when they are not explicitly trying to have a baby. This is, incredibly enough, a very popular idea and strategy. I say “incredibly” because there is no evidence that it works and no reason to think that it might. For all of human history people have had sex, and the people with the strongest urge to do so are just the young people that we are trying to convince not to (ironically, the potency industry for old men, whom nature has decided do not need to have a desire or ability to have sex, is enormous!).

There is compelling evidence that every program designed to keep young people from having sex is a complete, utter, and absolute failure. Indeed, an unending line of ministers and politicians who preach and pontificate about the issue are having sex outside of their marriages, and proving by their behavior the vapidity of their words. It is of no importance to people outside of their immediate families whether they apologize or feel bad. What is important to the rest of us is that, if they don’t have the common decency to stop being politicians and trying to make policy that affects us all, that they abstain from voting on any issue with any sexually-related dimension.

On the other hand, there are much more effective methods for “reducing the demand for abortion”. They are two: widespread, comprehensive and truthful sex education, and widespread, freely available contraception. Unfortunately, I see no support for these measures in the current bills or in the complete blather coming from the mouths of the hypocrites above.


Unknown said...


The problem is not that there aren't enough primary care residency slots -- there are plenty that go unfilled -- its that young doctors don't want to go into primary care and primary care doctors are leaving practice. We need to pay primary care in a very different way (More money, for starters), and they need to organize themselves so that they can take care of patients and cover nights and weekends.

Josh Freeman said...

I absolutely agree; I have discussed this on several earlier posts. Even if a bill gave "preference" to primary care slots, when they weren't filled, they'd use them for radiology, cardiology and ER.
Your point about organizing to cover nights and weekends is critically important for creating PCMHs.

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