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

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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 (http://www.pnhp.org/news/2009/december/pro-single-payer-physicians-call-for-defeat-of-senate-health-bill).

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.
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Will the President turn the “health reform” discussion around to real reform? Can he?

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Like many progressives in the United States, I’m wondering what it was all about. “It”, in this case, being the election of a President who cared about people, who was committed to health reform, who believed that single payer was the best idea for health reform, and that government existed not only, as Rousseau and Thomas Jefferson said, by the consent of the governed, but for the interests of the governed. And, to help him out, we threw out bunches of no-nothing Bush supporters and gave him almost (now, with Specter and Franken, actually) 60 votes in the Senate and an overwhelming majority in the House. So, what has happened? Not much. The painful story is detailed by Matt Taibbi in Rolling Stone, "Sick and Wrong", September 3, 2009, http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/. Sit down and keep your fist away from glass tables when you read it, but read it.

The President and the congressional Democrats we elected seem to have wasted the goodwill, enthusiasm, and hope for the future that we gave them, and mired it in a sea of legislative inertia, with the President not leading but watching, without apparent pain, as the rest of us face great pain. Taibbi writes: “The more the Republicans and Blue Dogs fidgeted and f****d around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.” He is of course, correct. The President and most of the “progressives” in Congress have moved away from the “left” and such “leftist” ideas as, first, single payer, and now probably the public option, and soon, it seems from even employer mandates or minimum requirements for what insurance companies have to offer us in the way of coverage. They have done this, ostensibly, to become more acceptable to Republicans, but without an ounce of chance of success. Every “compromise”, every give-back of a promise to actually provide the all the American people with the health care that they need at a price that they can afford and with a system that has at least some possibility of controlling costs has been given away with absolutely zero acceptance, gratitude or compromise from the MINORITY, the right-wing cabal currently called the Republican party. They and their supporters have had nothing at all positive to say. They continue to call the President a socialist or a communist, they object to his talking to students in school, and they get away with it.

The leadership of this movement, which seems to be mainly Rush Limbaugh and Bill O’Reilly and Glenn Beck (sorry, Sarah) is truly Neanderthal, truly anti-people. Many people have written about the why of this, of how all these White Men fear that they are becoming less than completely powerful, that the history that always gave preference to them and any old thing that they believe may have to be compromised with – well, everyone else – and that is the reason for their venom. The New York Times article on the proposed creation of a “day of special significance” on Harvey Milk’s birthday, http://www.nytimes.com/2009/09/05/us/05milk.html?_r=2&ref=us, quotes opponent Randy Thomassen of SaveCalifornia.com as saying “The bill is so broad it could encompass all kinds of things. Remembering the life of Harvey Milk could allow for gay pride parades on campus or mock gay weddings or cross-dressing. There is no prohibition of what the bill calls ‘suitable commemorative exercises.’ The sky’s the limit.”

Let’s look at that. Thomassen is worried that what? That other people might do things that he doesn’t like? Things that won’t (except I suppose psychically) hurt him. Those people won’t make him do any of those things, but he doesn’t want anyone else to be able to do them either. He could just say he is opposed to the bill, which of course doesn’t call for any of these things, without sounding like a finger-wagging scold. Does Thomassen, and do his friends, really think it is ok to make people do, or not do, things just because he doesn’t like it or it offends him? If so, maybe they could come here to Kansas and tell the other folks on the lake here to stop using their speedboats and jet-skis so I can have more quiet and be able to use my kayak without all that wake threatening to topple me. Hey, I am much more affected, limited in my choice of activities, by those power boats than he is by a Harvey Milk day or any of the bugbears he calls out. Why do people think they can – or should – tell other folks what they can do, as long as it doesn’t hurt them? How can we honestly condemn the fanatics in the Mideast who want to do the same thing?

But it is not funny. Thomassen may or may not be only a finger wagging scold, but these same ideas, these same limits, are often imposed on others, sometimes violently. And certainly this is not new, the reason Thomassen and his friends are worried. It is the same reason that it was in the 1920s and 30s. In his mystery novel “The Redbreast”, Norwegian writer Jo Nesbø has a character talk about the old men from Norway who volunteered to fight with the Nazis on the Eastern Front: “Oh yes, they’re still angry. At Third World aid, cuts in the defence budget, women priests, marriages for homosexuals, our new countrymen, all the things you would guess would upset these old boys. In their hearts, they’re still fascists.” [1] At least in the book the old men who believed these things had once been acknowledged fascists and Nazis. If you were to accuse the folks – the O’Reillys and Limbaughs and Becks and Thomassens who say these same things now, of being fascists, you would be attacked. But you’d be a whole lot closer to the truth than those who accuse Obama of communism are. George Bush is no longer President, and Dick Cheney is no longer – whatever he was – but the venom of the “we’re going to tell you – make you – do what we want” crowd is, probably as a result, more overt.

Meanwhile, regular people have a lot bigger issues; the Times (Sept 4, 2009) reports on the “Jobless recovery”, whatever that is. What I see is that people are still losing their jobs, just at a slower rate, but not getting jobs. So who is recovering? The bankers and Wall Street folks? If you can’t pay your mortgage and feed your family, if you don’t have a job, it is not a recovery. And let’s get this straight: Unless we’re going to go for big-time socialism and pay everybody a living wage even there is no work for them to do, the only purpose of the economy is to create jobs. This is actual people we’re talking about. They need work, and they need health coverage, and they need to know that they won’t lose their health coverage if they, again, lose their job.

The folks who are so worried about losing their coverage now are those who are, like the vast majority of Americans, not sick – yet. As Dr. Ferrer wrote as a guest in this blog on May 8, 2009 :

“The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year. None of those is engaging in discretionary spending or likely to 'value shop' for health care or to direct their own spending.”
Should they become seriously ill, it will be a sad time to find out what is NOT covered in their policies.

It may be too late for the President to do something. The Times doesn’t think so. Their very strong and atypically long editorial from September 4, 2009, “President Obama’s Health Choices” (http://www.nytimes.com/2009/09/06/opinion/06sun1.html?_r=1) gives very clear advice on what they think President Obama should say in his Wednesday talk to a Joint Session of Congress.

“Given the raucous, often ill-informed attacks on Democratic proposals over the past month, and the clear aim of most Republicans to oppose any bill, no matter how much he compromises, Mr. Obama now needs to spell out in some detail what he wants and how it would benefit both the uninsured and most other Americans as well.”

The Times takes on the Republicans and the “Blue Dog” Democrats, who are supposed to be deficit hawks but have distinguished themselves in this debate mostly by opposing any reform that will pour less government money into the pockets of insurance companies:

“The Bush administration and a Republican-controlled Congress enacted a Medicare prescription drug benefit that will cost the government almost $1 trillion over the next decade without raising or saving a penny to pay for it. They also passed tax cuts for wealthy Americans that will cost more than $1.7 trillion over 10 years, again without making provisions to offset the costs. Now they are complaining that $1 trillion for health care reform — fully paid for over the next 10 years — is too much to spend on a problem that has been festering for decades.”

And the Times has a suggestion for the President: “Rather than yield to Republican intransigence, the Democrats ought to resort to a parliamentary maneuver known as 'budget reconciliation,' which would allow them to push through most reforms by majority vote.” I don’t know about parliamentary process. Maybe President Obama can still say, “OK, this is the way it is going to go. We are going to have health care for the people,” and make it pass the Democratic majorities in Congress. I don’t know if he still can; worse, I don’t know whether, even if he can, he will. If he is going to really lead on making sure we get real, comprehensive, health reform, this is the time to do it. I hope he does, and hope it is not too late.

[1] Nesbø, Jo. The Redbreast. US paperback edition. Harper. New York. 2009. P. 257.
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