Healthcare reform is needed now more than ever

The following is a recently submitted letter to the editor:


To the Editor:
I am a psychiatrist in private practice in Atlanta who saw every day how broken our for-profit healthcare system is. In fact, calling it a system is inaccurate; Americans are covered by a patchwork quilt of private and public providers, all interested in shifting cost to someone else. As a result, the patient loses. 
I cannot count the number of times I have faced a patient in distress because a for-profit insurance corporation refused to pay for needed care, or found some excuse to defer or deny payment for services rendered. I cannot count the number of bankruptcies I have witnessed, survivors of trauma, cancer, and heart attacks whose insurance companies fought them at every step of the way. Simple human decency is absent in such a system, staffed by layers of faceless bureaucrats who have never met my clients making decisions in an attempt to maximize corporate profits.
Since insurance is a zero-sum game, every dollar that goes to CEO bonuses represents a dollar that could have gone towards a medication, a hospitalization, a pap smear, or vaccination.  A country that allows 45,000 of its citizens to die for want of health insurance, according to a recent Harvard study, does not deserve to call itself civilized. Half of those without insurance are children. 90% of the uninsured families are employed.
The United States remains the only industrialized country that does not insure all of its citizens. Now, thanks to the misinformation of powerful interest groups posing as populists, we may retain that status indefinitely. Thank you, Tea Party organizers. Profits have trumped patients once again.
Insuring our children is no more of a moral option than feeding them. Almost half a million Americans, some of our most vulnerable citizens, have died needlessly since 9-11 but there is no equivalent war on uninsurance. We should all be ashamed.  There is a solution, actually several dozen, but all involve making universal healthcare a reality. We can pick and choose from the best plans worldwide. I do not believe that the bill now threatened with dilution to meaninglessness is a great bill, but it is a move in the right direction. 
Americans deserve access to their own healthcare system. No child should ever have to die simply because their parents worked for Enron or were between jobs when the cancer was diagnosed. History will judge us not by how much a privileged few made in corporate bonuses, but by how well we took care of the least among us. Failure is not an option. We need healthcare reform and we need it now. 
Sincerely, 
Mark Vakkur, MD

Clara Barton House Tour

Clara Barton House Tour

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1/2/10

-         notes based on an outstanding tour given by Park Ranger Kevin Patti

Clara Barton was born on Christmas Day, 1881.  She was raised in N. Oxford, 50 miles from Boston; she had been raised a Universalist Unitarian.  Her father passed down a tradition of service; he had been a captain in the Army and founded a local Universalist church in Oxford, Massachusetts.

She was the youngest of 5 children, with a gap of 10 years from the next youngest.  They taught her and she became a school teacher in Massachusetts at age 17.

At age 30, she wanted to do something more, so she decided to pursue a university education, something hard for women in those days.  She went to Clinton Liberal Institute in Clinton, NY, run by Universalists.

She then moved to New Jersey which unlike Massachusetts had only "subscription schools" (private schools).  She could see many children running around during school hours, their parents unable to afford the fees.

She was willing to teach for free, and offered her plans to start a public school.  Her first day she had 6 students, the next day she had 20, then finished her first week with 40.  Word spread and more teachers were hired and eventually a whole new school was built around this revolutionary idea she had introduced.

Unfortunately, they didn't believe a woman, even the one who came up with the idea, should serve as principal, so gave the job to a man, whom they paid twice her salary.  She stayed on for awhile, but eventually left and ended up in Washington.

She lived in Washington, working as one of the first female federal employees, when the Civil War broke out.

Lincoln called for 75,000 volunteers to help defend Washington.  One of the first units to respond was from her state of Massachusetts; the 6th Massachusetts journeyed south by train, but had to detrain at Baltimore, march through the town to take another train to Washington.  En route, they incited a riot and this represented the first blood spilled in the Civil War on 4/19/1861.

Washington was not actually ready to house and support the Army it had requested, so Clara Barton used her mailing address to receive supplies for the troops that she solicited from her native state; the supplies came pouring in.

She was never trained as a nurse, but did a lot of nursing activities.   She earned a reputation as the "Angel of the Battlefield" during the Civil War.

After the Civil War she was touring Europe when she visited Geneva and learned about the International Red Cross.  She returned to America to form the American Red Cross at age 60.

The two men who bought the land on which the home was to be built had made a fortune in the food business and wanted to build a retreat, a wooded oasis separate from the City of Washington.  They bought  an amphitheater.  You could take classes, paint, sew.  It was called Chautauqua #53; there were many in the country at the time, where people  could go to get Enlightenment; its motto was "culture and education for the masses."  Teddy Roosevelt called Chautauqua "the most American thing in America."

A trolly was built to get people  here in an hour from Washington.  They thought about families, giving them a place to stay.

In the 1920s, however, the Chautauqua system had become less popular.   There were some traveling Chautauqua; you could also learn through the mail, for example, a farmer who could continue his education without leaving his farm.

The oldest book club in America was started here.

They offered Clara Barton a building and land for free.   She chose the design of the shelters she had constructed during the Johnstown Flood.

The Johnstown Flood occurred on 5/31/1889 and killed 2,209 people.   It was the biggest flood in American history.   The young American Red Cross responded, building shelters with big open central areas that would let light in and hot air out.   They used the design of this building to build what became the Clara Barton House.   When it was originally built, it had a stone facade, which Clara Barton removed to make it less ornamental.  She installed paneled walls behind which were stored an array of materials for disaster relief.  She also wanted to make it a home for herself and her volunteers, whom she encouraged to live there in residence.

She was very frugal, so used what she had rather than spent a lot on things she didn't.  She had a surplus of cotton muslin dressing, so used this to line the ceilings and walls (it is still visible today).

Her office featured a paperweight that was a shattered cannon ball from Gettysburg (she was not at Gettysburg, actually, but at Antietam, but always wanted to remind herself of the reason she was doing what she was doing).  She also had a book on display that she had written:  Red Cross Peace and War.

Next door was a room in which her staff wrote.  Every desk had a typewriter with special ink that would not dry right away; the paper was taken to a letter press so that copies could be made.

everyone including her was a volunteer.  They received and to this day receive no federal funding.

Dr. Julian Hubbell was a physician with some architectural training who helped design the building and served as an early American Red Cross executive.

We saw the room in the front where guests who came "calling" (this was an era where only 3% of the country owned phones in 1900) could be entertained.

The home was the first permanent home of the American Red Cross, which Clara Barton led for 23 years.

Also served as the National Headquarters from 1897 to 1904.

There were 10 bedrooms for volunteers.

She never married or had children but had a nephew who would stay in an upstairs room when he visited.

The building was also a massive warehouse, filled with tools and supplies for the disaster relief work they did.

They had $3,000 downstairs in a vault in case a disaster struck on Sunday when  the banks were closed.

In 1900, a hurricane struck Galveston, and the disaster was responded to from this house; the American Red Cross was on the scene in 8 days.

The Spanish American War also was responded to from this house.

 In 1904, at age 82, she resigned; there was some pressure to do so since she was getting older and the new organization became more bureaucratic and progressive after she stepped down.

The house remained her home however, and she did more writing here.

She lived through 23 American presidents but could not vote for any.   (The 20th Amendment granting women the right to vote was not passed until 1919).

Clara Barton died on 4/12/1912, 3 days before the Titanic sank.

The house became a set of apartments from the 1930s to the 1970s, luckily preserved by a management respectful of its history; they even kept the original furniture, which the guests used.

In 1975, the first unit of the American Park Service to be dedicated to a woman.

Minarets and Xenophobia

Some Musings on Minarets and Xenophobia
It seems all countries have a xenophobic, fear driven, nationalistic right-wing. At least in Switzerland, they are more overt, identifying themselves for what they are, an unapologetic anti-immigrant party that seeks to preserve what it sees as a quintessential Swiss culture that it fears will be diluted.
The thing that most upsets me about American politics is that we really have no viable left-wing (president Obama is a centrist, but our country is so far to the right that he is labeled a socialist by his detractors) and the right wing does not admit it is an extremist fringe. Instead, it calls itself Christian, pro-life, pro-family, pro-military, pro-freedom, etc. They are convinced that they represent the mainstream of America, the heartland, that they are even populists while denying healthcare to poor children and promoting tax cuts to the wealthiest 1%.
I find this Orwellian twisting of language to be highly deceptive and makes it much harder to attack the deep-pocketed corporate backers, fundamentalists, and just plain wackos who make this movement what it is. It should be marginalized, and probably would be if we had a decent education system, forced radio stations to impose the old regulations regarding political balance (in other words, finding something reasonable and educational to replace or counter-balance four hours a day of fascist idiots like Rush Limbaugh), and somehow got Fox news to either turn down its rhetoric or be marginalized for its extraordinary bias and distortions.
I really believe that the last two factors, perhaps along with the Internet and the proliferation of blogs appealing to narrower and more extreme slices of the political spectrum, are doing more to destroy our country and make it almost impossible to get anything meaningful done. I was absolutely shocked to see what the Republicans did in the town hall meetings with their pictures of Obama with a Hitler or a Stalin mustache ( depending on their mood I suppose), equating insuring our children with Nazi concentration camps. the fact that this nonsense along with a misinformation campaign regarding the president's citizenship is actually getting traction is what I find most upsetting.
At any rate, I think that most people fall somewhere on the spectrum between Dick Cheney and Martin Luther King. Cheney sees the world is a dark and Hobbesian place where resources are limited and there is not enough food or fuel or real estate to go around, so only by seizing resources and throwing up walls and threatening violence against those who try to cross them can we keep our comfortable position in the lifeboat. There is probably some survival value in this extreme distrust of otherness but in a world of instant communications, jet flight, and nuclear weapons, such an attitude is dangerous and ugly.
King of course envisioned an America that could live up to its promises, that could treat all Americans as God's children, as he put it, in a decent, just society that judged a man by the content of his character, not the color of his skin. He did not believe that feeding poor black children in Georgia would bankrupt the United States and felt that white racists were as harmed by their vitriol as their victims.
I think the only way to win against fundamentalists and nationalists is to constantly challenge their nonsense and to use their metaphors against them. They worship physical strength and the threat of violence, so point out repeatedly that their world view is actually one of weakness and fear, a desperate and ultimately unsuccessfully attempt to remain static in a fluid dynamic multi-cultural world.
Calling a nationalist cruel or mean spirited will only encourage them since they will see this as a compliment. Calling them scared, defeatist, or even anti-American ( since they are so convinced that we must fail where the French, Germans, Swiss, Japanese, Australians, British, etc. all succeeded to various degrees ( at least in the case of healthcare)) seems to get their attention.
Religious metaphors, which after all mostly reflect remarkably concordant ethical injunctions of the Axial Age philosophers and belief systems, held up as a moral mirror is helpful, speaking for example of our duty to provide for the least among us. Christians don't have to be told who said this, so without ever explicity bringing up religion or metaphysics, you can state a universal truth in a language instantly accessible to them. It becomes very hard for them to take the moral high ground when universal healthcare is framed in Christian ethical terms. They may then revert to the hard-nosed, clear-eyed, even cruel realists they like to see themselves as ("well who is going to pay for it?" etc.), but that forced shift might plant seeds that later allow them to adopt more progressive views in traditional religious garb.
I think that nationalists and fundamentalists, as Karen Armstrong points out, are deeply afraid and threatened by change and modernism. Ignoring their bluster and challenging their fear is probably what is going to get them to see that building walls enclosing borders will only delay the inevitable and to deprive their country or society of a rich influx of new ideas and points of view.
The recent Swiss anti-minaret ban was embarrassing, but I feel a little hesitant to be too critical of the country where I am a host. I do not believe that a ban that discriminates against one religion and one religion only so blatantly will stand muster in the EU, where Switzerland is not a member, but wants to do business with them.
I kind of like France's approach, where all overt religious religious displays in the public school system are prohibited. I suppose that we have a similar approach in the United States, although it has had the unfortunate side effect of watering down local traditions such as Christmas plays or musicals to generic holiday specials.
In response to the anti-minaret ban (which passed by a plurality but not a majority of the 20% of people who cast votes, many of whom were mobilized by the right wing who launched an incredibly dishonest campaign playing on people's fears and prejudices of Islam), a group here has filed a petition to make the 4 Switzerland mosques UNESCO world heritage sites. Better to light a candle than curse the darkness. This would cement Islam, representing 4.6% of the Swiss population and growing, as part of Switzerland's cultural legacy.
It wasn't so long ago that people were saying the same thing about Catholics or Protestants, French speakers or German speakers, but I really don't think many intelligent people care that much if at all about such silly differences. The problem with Islam is that it has done a poor job of emphasizing itself as a sister religion to Judaism and Christianity; the prophet Mohammed had his followers pray to Jerusalem until he felt that he had been betrayed at the battle of the ditch at which point he had them instead pray in the direction of Mecca. He saw himself as continuing the Abraham a tradition, not starting a new religion per se, just as the Jews who later came to be called Christians saw themselves as Jews with their latest prophet or Messiah in the tradition of Isaiah and Amos.
The other problem with Islam I suppose is that some cultures based on sharia law engage in practices that are much closer to those of the brutal, superstitious, misogynistic, sexually tormented society of biblical times. Modern Christians do not realize how recently they have been secularized, shedding biblically condoned and encouraged practices we now consider barbaric, such as stoning of adulteresses or slavery. The contempt for women, the quickness to murder them, and the superstitious dread of certain illnesses such as epilepsy or leprosy has only very recently been replaced by modern humanism and scientific rationalism, although few Western European and American Christians will acknowledge, understand, or admit this.
Therefore, they look at the more extremist Moslems, such as those who force their women to cover completely before going out in public, shaking their heads at the backwardness of such people without realizing that they are not really looking across a religious divide as much as a time divide; there were all Mediterranean monotheistic faiths only a century or two ago in some cases. People were burned alive in Geneva by John Calvin and his followers who had a version of rigid compulsory theocracy that would have made modern Iran looked incredibly progressive and liberal by comparison.
The fundamentalists in the Arab world like those in ours are also deeply afraid of change and modern concepts such as equal rights for women and a healthier less reproductive centered view of sexuality, but of course they will lose. I think they know that at some level; if they truly had faith that God was on their side and all that, what need would there be to invade and occupy other countries on one hand or to fly airplanes into buildings on the other?
I hope in 50 or 100 years we will look back at all this is so much silliness. No doubt by then we will have moved on to a whole new set of petty prejudices and things to be afraid of.

Why the Party of No Has Got it Wrong on Healthcare

I recently had someone post some critical responses to a post I made on my Facebook page regarding an interaction between a Congressman and a heckler with a defaced Obama poster in which the president was made to look like Hitler. I answered her criticisms one by one the best I could. If the Republicans (Hell no! Status quo! Hell no! Status quo!) think our healthcare system is doing such a heckuva job then why are they manufacturing arguments and answering questions no one has asked?

Q: Why can't we try [healthcare reform] at the state level - name a single state that has succeeded in providing universal healthcare?

Some problems are so large and diffuse that a regional or local solution will be quite difficult. Each of the cantons in Switzerland, however, which are most analogous to states in the United States, has come up with its own variation on a theme with excellent results. The federal government provides a leadership role, however, as indeed it must. I do not understand this insistence on finding a local solution before providing healthcare for all our children. Cancers and trauma and diabetes and schizophrenia do not respect man-made borders; why should we throw them up as an excuse for continuing to deprive tens of millions of our citizens with healthcare? How about this: why not name a state that has successfully won a war or put a man on the moon or developed a polio vaccine? If the Party of No had been in charge during the space race, we would have never launched a rocket until West Virginia could convince us that its rocket program was independently as good as Alabama's.

There is no state in the union that does not already receive much of its healthcare funding from the federal government, either through Medicare or its federal employee retirement programs, or CHAMPUS or Tricare for military members and their families. Therefore, it would be impossible to answer your question unless those programs, all of which are wildly popular and much more efficient than their for-profit counterparts, are abolished.

I don't think all of this applies to the United States.

Why not? Is there some genomic variation that occurs when people cross the Atlantic or Pacific to reside here? Is our government that much stupider than that of France or Germany? Do you really think Americans would rush out and get breast cancer if the treatment for it was suddenly affordable?

This argument is often advanced by those who advocate doing nothing about the uninsured or underinsured in this country. Even if there were some unique qualities to American society, surely SOMETHING must be done for the least among us. Simply because those drowning in the water might not all fit perfectly into a French or Swiss lifeboat, does that mean we should give up on trying to save them?

At any rate, there is no evidence that the distribution of illnesses is that much different for American populations than for those in European countries. Obesity rates are much higher in the United States but smoking rates are lower. What is clear is that if you get an illness in the United States, particularly a chronic illness, and you do not have health insurance, your morbidity and mortality are much higher. Our abortion rate is also much higher than in any Western European country, and those who are concerned about this might be interested to know that lack of access to healthcare is an independent risk factor for abortion (as is poverty, but adjusted for income, you are more likely to seek and obtain an abortion if you are uninsured). If you are Pro Life as it has become so narrowly defined in our country, you should be for universal healthcare.

France's plan is a failure from what I have heard because it causes too much tax and the country has a history of high unemployment as a result.

You should tell this to the French; they would be quite surprised to hear it. This is also why it is so important to get the facts, not just listen to something you might have heard.

You should also tell this to the World Health Organization (my wife's employer, by the way), which recently rated France's healthcare system #1 in the world! (The United States, by comparison, was #37.) If France is failing, let's try to replicate their "failure."

At any rate, this whole "failure" business should be properly defined. A truly failing healthcare system is one in which there is some measurable difference at the population level in some measurable health outcome that can't be explained by other variables. The healthcare systems of the Soviet Union, for example, despite theoretical universal access, would have been a failure in this regard, as would the healthcare systems of many impoverished countries that simply can't afford access or the infrastructure to deliver it. If a system is truly horrible, you should see a difference in life expectancy at birth. The French enjoy a life expectancy of 80 years, greater than ours, so clearly they must be doing something right.

If failure is simply measured in cold, hard dollars and cents (or Euros and centiemes) then this also is measurable. The implication you make is that France is bankrupting itself through its healthcare expenditures. You further speculate that these higher expenditures cause higher taxes and higher unemployment than in the United States.

To make this argument, it would seem necessary to prove that France spends more than the United States on healthcare, a lot more. As it turns out, France spends LESS, a lot less. As David Gewirtz recently put it, "In fact, we spend more on health here in the U.S. than the entire GDP of the United Kingdom, France, and Canada — and just below the entire GDP of Germany. Our health care cost is bigger than England’s entire economy! Interestingly, in a country where we’re arguing the issue of a national health care system, the U.S. spends more than twice (as a percentage of gross domestic product) than either the U.K. or Canada, who have national health programs. The U.S. spends 16.6 percent of its GDP on health care, while Germany, France, and Switzerland spend 10.1 percent to 13.0 percent — and India and China spend less than 5 percent." - http://ac360.blogs.cnn.com/2009/08/19/the-healthcare-hostage-crisis-how-much-does-this-all-cost/

So if the premise of the argument is false, one need not address the conclusions; if taxes and unemployment are higher in France than in the United States, the explanation cannot be healthcare because their healthcare costs are lower! Unless of course you are trying to make the point that France would be better off if it put its unemployed to work in a massive for-profit system such as ours, perhaps as claims processors (something France does not need) for all the different insurance companies.

Switzerland's employment rate has been far lower than that of the United States yet they have managed to cover all their citizens. Unemployment statistics are deeply misleading also in the case of the United States, where someone could work 3 minimum wage jobs and not have any health insurance or retirement benefits. That person would not be considered unemployed, but are they really better off than the worker in the McDonalds in Berlin who earns over $21 an hour and has healthcare, social security, and publicly financed college education to boot? When someone is employed in Europe, they are really employed, not just getting by without benefits or any hope of a better life. As a result, there are virtually no slums, massive poverty, or United States levels of crime (which are highly correlated with poor dispersion of income).

People still have to pay if they want good care and shorter waits. I do agree that any of these plans could be tried in a state of the United States but we (as you know) are a completely different country than Europe.

No, I do not know this. Our government is a logical outgrowth of the Anglo-Saxon constitutional parliamentary system. We do not have a monarchy, but do have a much more powerful, independently elected Executive. This American exceptionalism is largely a figment of our own imagination, with a little help from Donald "Old Europe" Rumsfeld and Dick "Freedom Fries" Cheney. Otherwise, our systems are quite similar. Our governments already spend far more on healthcare and social security programs than they do on any other government activity; the difference is that for some reason the word "socialist" is a bad word on your side of the Atlantic. (In fact, I heard someone quip that our government is essentially a social security benefits administrator with a lively arms business on the side.) Because of our anathema to anything that even smacks of central planning, we tend to do it badly and in fits and starts. FDR managed to establish Social Security in 1935; Republicans have been trying to kill it since its birth, but it remains one of the most popular programs. (I even read an article in Barrons about 2 years ago that FDIC was a quaint New Deal program that should be killed because despite its trivial cost bank failures just weren't a problem anymore… thank God that advice wasn't taken!) LBJ got Medicare done, another wildly popular program covering all over 65 and the disabled and doing so with less than 2% overhead, something for-profit companies could only dream about. Nixon and Clinton both attempted to advance universal healthcare initiatives, but both were shot down by extremely well-funded misinformation campaigns by those who profited from doing nothing.

Now we are at a similar crossroads but the stakes are higher, the number of uninsured or underinsured has skyrocketed, and the costs of our managed care for profit experiment seems to be rising with no end in sight. Republicans say we can't afford to join the ranks of every other industrialized country in the world and insure our children but the evidence seems to suggest that we can't afford not to.

What proof do you have the protestors are packed in by anyone.

- Representative Phil Gingrey from Georgia advocated on national television that protestors – almost all white and Republican - bring guns to town hall meetings. (http://rawstory.com/08/news/2009/08/18/rep-gingrey-encourages-guns-at-town-hall-meetings/)

- Americans for Prosperity, the front organization created by billionaire David H. Koch who also tried to organize "tea parties" in April (remember those?) to create the illusion that real people, not just a tiny elite, would lose if the tax cuts for the richest Americans were ever rolled back to Ronal Reagan levels - has bought millions of dollars of television ads and has even sent a bus across America to mobilize opposition to healthcare reform. On its website, it lists town hall meetings to encourage activists to attend.

- Conservatives for Patients’ Rights, led by Rick Scott, former Columbia/HCA CEO, a healthcare company that paid $1.7 billion in fines for stealing from the taxpayers to profit themselves (overcharging government programs in the 1990s) - is working with another PR group responsible for the Swift Boat ads that defamed a decorated wounded Vietnam veteran (but did so effectively enough to tilt a tight election in favor of a draft-dodger who had not completed his service with the National Guard).

- FreedomWorks is a group, led by Dick Armey, a former Republican House majority leader that has been fomenting hysterical levels of opposition.

The protestors are grossly misinformed. Indeed, if they were informed, they would put away their Hitler mustaches and assault rifles and act like adults. Yes, it will be difficult making the transition to a system that covers all of our citizens, but let's disagree about means, not ends. The misinformation is coming from the top. When someone like Sarah Palin comes out with a statement as she did on her Facebook page in which she refers to the idea of insuring our children as a "nationalized healthcare plan" and "disturbing" and "downright evil" and says "we’re saying not just no, but hell no!" this language only incites the type of violent rhetoric and creates the mindset of a lynch mob (and with the ugly addition of automatic weapons seen by the predominantly white Republican protestors against the healthcare initiative of our first African American President, that metaphor is far from accidental).

Palin makes the ridiculous assertion that healthcare rationing will begin with the current reform (implying that such rationing is not occurring either de facto (those without insurance get no treatment) or de jure (apparently Ms. Palin has not heard of prior authorizations, restricted formularies, pre-existing illness exclusions, or lifetime medical caps, all of which represent forms of rationing brought to you by the for-profit healthcare industry).)

She goes on to claim that the "sick, the elderly, and the disabled" will be hurt most even though no one is proposing major changes to Medicare (which currently covers the last two categories) and it is hard to see how giving healthcare insurance to someone who doesn't have it is going to hurt them.

"The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care." Yes, she really said this. Death panels. Read it and weep: http://www.facebook.com/notes.php?id=24718773587&start=10&hash=34d9414b0365b1e460511f13215ccb7d

Now I know most intelligent people have long ago stopped listening to Sarah "in what respect, Charlie?" Palin but some still do and many who are less educated or less informed will wonder why someone who is so well-connected to have been tapped to be a heartbeat from the presidency would talk about death panels if they didn't exist. Those people, showing up armed with their guns and their defaced Obama portraits made to look like Hitler (Hitler!) didn't just get there accidentally. If such panels existed, I would be mad too, and I might not be interested in debate or listening to what the other side had to say. Or even reading the actual bill. Sarah said it and I believe her. End of argument. (Remember, these are the same people that believe that reason and compassion are tools used by the devil to trick you out of your pre-destined front seat to the Rapture during the End of Times (which Sarah Palin believes will start in Alaska, boosting tourism (I wish I were making this up)).)

The latest polls show that over half the US is against government run health care and are very upset by the prospect.

If this argument is offered as an excuse for those who believe insuring children is the moral equivalent of mass murder, two things must be true: 1. most Americans oppose government run health care and 2. (more importantly) that the bill in question advocates it.

Unfortunately for the Party of No, reality once again remains a tenacious foe.

I am against a government-run health care system. So is President Obama. Thank God the bill that Palin condemns as "downright evil" does not propose a government-run healthcare system so we don't have to waste time arguing about a non-issue. Or do we?

It is true that disinformation campaigns work. We know that just as Goebbels knew it. A lie repeated often enough will be believed, so it's no surprise that the percentage of Americans supporting the current healthcare reform has slipped from over 50% to about 42% of American voters (according to a Rasmussen poll). And with all this talk of death panels for the elderly, what do you know? 56% of those over 65 oppose the plan whereas those under 30 support it by a 2:1 margin.

However, although the Swift Boat campaign in progress may have slowed down the current bill's momentum, it is not true that Americans do not support the idea of government-run healthcare in general. In fact a recent New York Times/ CBS poll showed a whopping 72% of Americans supported a government-run program. Only 20% were opposed, about the same as the percentage of people in other polls (18%) who believe the Sun revolves around the earth. Half of Republicans would support such a proposal, as would 9 of 10 Democrats and 3 out of 4 independents. Other findings:

- 85% of Americans believe that the healthcare system needs radical reform.

- only 18% of respondents trusted the Republicans to improve healthcare

- 57% trusted the Democrats more. (even 1 out of 4 Republicans trusted Democrats more);

- 6 in 10 Americans are willing to pay more in taxes to support universal healthcare. 87% of Americans believe the inability of people to pay for needed tests and treatments was a serious problem. 1 in 4 said someone in their household had skimped on medications because of costs and 1 in 5 had skipped a recommended test or treatment. Only 75% of respondents feel that insuring everyone is more important than controlling costs (although the experience of every other country is that you can do both). - source

So there are some good, intelligent arguments, most based on a brutal Darwinian view of the world, for continuing to deny healthcare to our children while for-profit healthcare companies thrive. None are moral arguments, unless you really believe that human life is less worthy of protection than lower tax rates, or unless you have a Timothy McVeigh view of the federal government as always-evil-all-the-time (with the exception perhaps of those federal employees in uniform who are covered by the world's largest socialist healthcare system).

But the arguments the Republicans are fighting are ones no one is making ("death panels!" "government-run healthcare!" "mandated abortions!"). It makes me think that they know how weak and selfish their position is. They seal the argument when they use brownshirt tactics that shut down debate and guarantee failure and maintenance of the status quo.

Quiz someone who is all worked up about this bill for 5" about what is actually in the bill, or how many people really drop dead in waiting lines for medicine in Canada or the UK, and you will get either a blank look or an anecdote about a friend of a neighbor's brother-in-law's cousin who once knew someone in Canada who didn't like their doctor. Good thing that never happens here.

If you really think that spending 16% of GDP, more than any country on the planet, on a bloated for-profit system that leaves nearly 50 million Americans behind, 90% from working families, half children, then go for it. Get out your Hitler mustache and Obama poster. Hell, bring along your AR-15 (your congressman says there's nothing wrong with that). Make yourself and your country the laughing stock of the world. Guarantee this effort will fail also. But you're still left with the same high premiums, out of control deductibles, and will still be a paycheck away from financial disaster.

You will have your talking points though and maybe even a signed Sarah Palin poster and that's worth something, I guess.

But there are people out there for whom this is not a theoretical debate and I have worked with many of them and it appalls me.

I have plenty of anecdotes also, like that of the paramedic broadsided by an ambulance but then told by her private insurer that the physical therapist she found and liked was not part of her plan, so she would have to drive across town to see a stranger who offered substandard care.

Or the man who mortgaged his home to finance his chemotherapy only to be told he needed another round and unless he could find $100,000 in cash, he would die (he had private insurance, by the way, but blew through his million dollar lifetime cap so they dropped him midway through his cancer treatment… perfectly legal in America).

Or the countless numbers of patients who ended up in jail or worse because they had no mental health benefits or after 72 hours in the hospital for psychosis or depression or mania the for-profit managed care "coordinator" determined (without meeting the patient) that they had reached the maximum benefit of inpatient treatment for which they would pay anyway.

I think I have a different definition of evil than Sarah Palin. It's similar to Martin Luther King's, when he said that our generation must atone not just for the vitriolic words of the bad people but for the appalling silence of the good people.

NPR Commentator Ken Harbaugh's "Most Soldiers Return from War Just Fine" (NPR, All Things Considered, 12/6/07) misses the point

Email response to a story heard on NPR:

Commentator Ken Harbaugh's "Most Soldiers Return from War Just Fine" (NPR, All Things Considered, 12/6/07) misses the point and comes dangerously close to glorifying war.

As a psychiatrist who spent several years in the VA system treating veterans from every conflict from World War II to the Iraq, I can assure Mr. Harbaugh that the idea of a generation of traumatized veterans is no myth. The fact that none of his friends seem traumatized by war is anecdotal and misleading. Comprehensive studies conducted by the military and the Department of Veterans Affairs have shown that about a third of those exposed to heavy combat suffer from posttraumatic stress disorder. Many are ashamed of their symptoms, so may not confide them even to close friends, and others do not develop the disorder until years after the trauma.

War, particularly in its industrialized, high intensity, mass casualty modern form, is toxic to the human central nervous system. No one claims that 100% of soldiers are permanently traumatized by their experiences. In small doses, with proper support, training, and rotation, combat will not permanently traumatize most of those exposed, but repeated tours in a hostile foreign land with no clear front lines or rear areas is a recipe for a psychiatric public health disaster.

The fact that someone is proud of their service says nothing about whether they were traumatized. In fact, survivor guilt is more often the rule than the exception.

Mr. Harbaugh engages in some well-intentioned stereotyping of his own, when he implies that a veteran suffering from posttraumatic stress disorder could not be employed, out of jail, or grateful for having served.

As a West Point graduate, I am deeply appreciative of many aspects of military service, but let us never forget the words of President Carter that war, although sometimes a necessary evil, is always evil. I agree that caring for the traumatized veteran is a high moral imperative, but not starting unnecessary wars in the first place is an even higher one.

Mr. President, We Can't Afford NOT to Insure Our Children

October 6, 2007: Mr. President, We Can't Afford NOT to Insure Our Children

President Bush vetoed a bipartisan bill expanding healthcare coverage to 10 million children. The president believes denying healthcare to children today is preferable to the possibility of government-run healthcare for everyone tomorrow. His stance betrays two flawed economic assumptions: 1.) that government and corporate bureaucrats are not already heavily involved in running the healthcare system; and 2.) that shifting the government involvement from protecting corporate profits to guaranteeing universal access would lead to economic and medical disaster.

American healthcare is delivered via an uncoordinated patchwork quilt of public and for profit systems. Medicaid covers the very poor. Medicare covers the old and disabled. Managed care companies choose from among the employed healthy who are wealthy enough to pay premiums but not sick enough to require much treatment. The children Mr. Bush feels we cannot afford to insure are among the 47 million Americans who fall into the enormous gaps between government and for-profit systems. CEO William McGuire was paid $124.8 million because his company, United Health Group, could cherry pick from mostly healthy employed Americans. Since healthcare insurance is ultimately a zero sum game, in a very real sense, those $124.8 million represented thousands of denied pap smears, mammograms, cancer treatments, vaccinations, or denied new or renewing patients. Shockingly highly paid CEOs represent an enormous government-created transfer of wealth.

It is no coincidence that drug company lobbyists on Capitol Hill outnumber lawmakers. Big pharma knows the source of its extraordinary profit margins is no invisible hand. Americans pay a third more for the same medications as do Canadians or Europeans even though many of those medications were created with taxpayer-funded research and development because our government guarantees and enforces drug company monopolies for several years after a drug is launched. The premium we pay represents a de facto government subsidy to drug companies, enforced with taxpayer-funded courts and policing agencies and possible because of the absence of a Walmart-like agency with the economic muscle to negotiate lower prices for all of us. (Indeed, the bill creating Medicare drug benefits expressly forbade the government from negotiating lower prices at all!) Intellectual property rights should be protected. But as the President misleads us with talk of "government-run healthcare," let's not forget that we've already got it. I believe the government should protect patients as zealously as it protects patents.

Since the government is heavily involved every stage of health-care delivery in this country, let's stop the posturing and figure out how to make it work for us rather than against us. Those who believe free markets do no wrong and governments nothing right should pack their bags for Zimbabwe.

The brewing battle over healthcare is really not between advocates of free markets versus supporters of government intervention. Instead the fight is about what the role of an already heavily involved government should be. Currently most of the activity of the government is directed toward enhancing the profitability of the managed care and drug companies. Is it so outrageous to demand that our government shift its focus to protecting the taxpayers who support it while advancing universal access to healthcare, at least among our children?

Currently, those without insurance have no advocate. There is simply no agency, private or public, who takes ownership of this growing problem. To continue to insist that the status quo should work in theory despite mounting persistent evidence that it does not work in practice verges on psychotic. If the current mix of public and for profit insurers could deliver healthcare efficiently and rationally, they would have long ago. 47 million Americans, 90% of them working, 50% of them children, would not lack health insurance. Infant mortality, vaccination rates, and life expectancy at birth would not be markedly worse than those of countries with universal health coverage. There would not be the scandalously higher mortality rate among those without insurance. We would not pay so much more - 16.5% of GDP in 2006 - on healthcare but get so much less.

Let's not forget that access to healthcare, unlike access to a luxury car or a larger home, is ultimately a matter of life and death. We can forgo luxury expenditures; we should never forgo healthcare for our children.

President Bush fears something sinister about a government spending as much on children's health as it spends in 9 weeks in Iraq. The president who successfully frightened Americans into believing that Saddam Hussein had to be stripped of weapons that he did not have failed to convince us a fully funded public health system would be an apocalypse. He failed because most American families experience in practice the system he seems to know only in theory. If the President spent a day in a public health clinic, or even in my psychiatry private practice, he would understand the futility of giving tax credits to the poor who pay no taxes. There is something almost comical about a president expecting those denied private insurance to find solace in his promise that the government will not provide it either.

The apocalypse of American healthcare is now, not in the form of a government bureaucrat deciding healthcare but a profit-driven managed care bureaucrat denying it. The exact details of any solution are less important than our commitment to get it done. It is hard to envision any proposal that would not heavily involve the federal government, at least as a referee. Get over it.

My modest proposal: expand Medicare to cover all American citizens. As a private practice psychiatrist who accepts all major private plans as well as Medicare and Medicaid, I generally elicit surprise when I tell people that Medicare is one of the best plans to work with. They were among the first to go electronic, and they pay promptly and well. You would never know it from Bush's misinformation, but Medicare is far more efficient than any private system. The Medicare administrative costs of about 2% are comparable to the administrative burdens of most national health systems. This is in contrast to private plans' administrative costs of 15%-25%, including compensation of top executives, lobbying, marketing and advertising. The fact that Medicare can deliver healthcare to the old and disabled at a fraction of the cost of private plans means that if the risk pool were expanded to the young and the healthy, the economy of scale savings would be enormous, driving down administrative costs even more.

If universal coverage is too much to swallow, why not at least expand it to cover our children? If those under 18 and over 65 were guaranteed healthcare, we could always work on those in the middle later. Families relieved of the burden of finding and maintaining continuous private insurance for their children would experience huge premium savings on their family policies. Those who develop chronic and persistent illnesses before age 18 could seamlessly shift into a Medicare disability policy as adults. Such a change could end overnight our failed for profit managed care experiment.

Bush misrepresents Medicare and other public programs such as the S-CHIP program he vetoed, confusing government-refereed with government-run. The Veterans Administration is a government-run, centrally planned bureaucracy. Medicare and Medicaid, on the other hand, simply pay a benefit, or supplement a private policy; the benefit can be taken to any participating provider. Such a system offers far more choice than a for profit plan which restrict choice to contracted providers (some pay for out-of-network services, but usually at a steeply discounted rate). The President is simply wrong when he says that Medicare restricts freedom; to the contrary, it allows optimum matching of client to provider and introduces market forces and competition to regions currently carved up by HMOs and managed care companies.

When Bush, a heavy recipient of pharmacy and health insurance campaign donations, speaks of the threat of squeezing out private insurers I wonder if he would have opposed the development of the light bulb because of its impact on the candle industry, or fought the polio vaccine because of its economic threat to iron lung manufacturers. A healthcare system exists not to protect one favored group of workers but to serve patients. Determining the optimum mix of private or public systems should be driven by what works, not who works.

No doubt, we could help many of the for-profit bureaucrats and claims processors get jobs in an expanded Medicare program. Some might even become healthcare providers in the countless clinics that would spring up as millions of previously uninsured or under-insured Americans took their new benefit to the physician of their choice. Consumers and providers will vote with their feet, responding to market incentives and differences in quality of care. Providers will have a strong incentive to provide excellent care and customer service since their patients will no longer be constrained by insurance to see only a limited number of physicians. Hospitals and clinics could downsize their billing departments, reducing overhead and ultimately fees. Emergency rooms, currently the only place where the uninsured cannot be denied care, could focus on those truly in crisis.

Corporations should embrace universal healthcare. Aggregate profits should soar as the liability for current and future healthcare is shifted from individual corporations and shared fairly by all of society. As earnings rise, so too should stock prices, fueling a tremendous bull market. General Motors could focus on making cars instead of providing healthcare, and would no longer be at such a competitive international disadvantage. Many lawsuits motivated by the uninsured desperate to get someone to pay their medical bills would disappear, reducing litigation and insurance costs. Millions of Americans stuck in dead-end jobs could leave if insurance were de-linked from employment. They could start businesses or return to school. Our entire society would benefit from the new outburst of labor mobility as millions of Americans moved into optimally-matched positions. Millions of Americans dependent upon Medicaid or Medicare disability could re-enter the workforce confident they would not lose their healthcare as a punishment for appearing too functional.

If we can afford to spend a trillion on the invasion and occupation of Iraq without suffering a collapse of our society, then we can certainly afford another $30 billion to insure 10 million more children. After the initial transitional costs, the savings will be enormous. Delaying what is probably inevitable only compounds the ultimate total cost. Not paying upfront for the universal healthcare of all Americans is about as economically wise as making a minimum payment on a large credit card bill; short-term cash flow is improved but long-term liabilities snowball.

Since universal health-care coverage is a tough sell in, let's at least agree to cover our most vulnerable citizens. No child should ever go without health insurance, at least not in a wealthy country such as ours. President Bush believes we cannot afford to insure poor children; I believe we cannot afford not to. Indeed, how we treat the least among us is the ultimate measure of the strength of our country. As the bumper sticker says, freedom isn't free, but either is healthcare. Let's stop the ideological posturing and misinformation campaigns and get to work.

On Conspiracy Theories

I agree that certain individuals today and throughout history have had a disproportionate impact on how decisions are made, resources allocated, rules favoring one group or another are tweaked or modified or overturned. Many are unelected and many work behind the scenes. The Federal Reserve Board is a good example.

However, I also believe that there are constraints in the equation even among the most powerful. Louis XVI was an absolute dictator but was murdered by his own people. Napoleon rose to power and declared himself emperor and established an empire that continues to influence us today (the legal code of Louisiana, for example). Mao murdered millions and had a centrally planned economy but the heirs of his system find even they have had to make some modifications after 1989 that the early leaders would have never dreamed of. They didn't do this because they wanted to but because they had to. The people demanded it and even an absolute monarch must at some level heed the will of the people.

My view is that this tug of war between the few and the many, between the rich and the poor, the owners of capital and the workers has been playing out since the most primitive cultures developed surplus income, and with it, the ability to accumulate wealth. The history of ancient Greece, Rome, and the more recent conflicts in Europe over the past 200 years between the liberals (advocates of representative parliamentary democracy) and conservatives (monarchists of one form or another) seems a messy, noisy struggle over how best to organize a society. I believe several different formulae work. For now the liberals have won in the West, but the Chinese hybrid model or a Singapore model may be demonstrating it is at least a viable alternative.

Rupert Murdoch may buy papers, but ordinary people have to read them. The oligarchs may declare their currency must be at a certain level by fiat, but clearly traders around the world may have different opinions. We may want to cut interest rates to goose the economy, but there are real world consequences in terms of the dollar, inflation, etc. The small group of people you feel is in charge of the world may desire to punish Iran, but Russia clearly is not interested in going along with this plan. They may want to punish China, but China helps buy a billion dollars of our debt every day. They may want to be greeted as liberators and plant Jeffersonian democracy in Iraq, but the Iraqi people clearly have other ideas about the matter (and they are prevailing despite all the power and high technology and concentration of power we enjoy).

If the oligarchs completely ruled everything, the world would look much more like Europe in the 1200s than the West today. We would not have Medicaid, Medicare, Social Security, the 5-day week or the 8-hour workday, OSHA, the FDA if the owners of capital, who gain nothing directly from these programs and would gain quite a bit from their elimination, if the wealthy few were entirely in charge. True, they got their tax cut, a massive transfer of societal wealth away from the poor to the richest 1% and their war, which was fought disproportionately by the poor, and they managed to convince Americans that the estate tax (the "death tax" as they called it) was a populist issue. But they could not manipulate the 2006 thumping and have little power over the 2008 one to come.

Conspiracy theories implicitly assume that there is one set of levers to control the engine of state and that whoever has their hands on the levers is a unified group with a uniform agenda. History strikes me as much more messy than that. As Kurt Vonnegut said, we are all just farting around down here and anyone who tells you differently is lying.

Our current system, the product of liberal democratic movements mostly in Western and Northern Europe, is at once fragile and strong. The fact that the many have a voice means that voice can be manipulated, and the current occupants of the White House demonstrate that manipulation can be executed with breathtakingly bold effectiveness. But even viewers of Fox News eventually get wind of an external reality, a relative in New Orleans or a friend in Iraq or a surprise jump in their family health insurance deductible, and they usually get it. A little slow on the uptake, but they do get it. That is the strength of our system, that despite all the lobbyists and the secret energy meetings and the sidestepping of laws and oversights, in the end, ours is a government of the people, by the people, and for the people. Governments, particularly popularly elected ones, do a lot of stupid things that most certainly do not always represent most of the people, but on balance they usually end up getting it right.

If 200 years ago, I had said that one day slaves would be free, blacks could vote, women could testify in court and even vote themselves, that Senators would be directly elected and even 18 year-olds could vote, anyone alive would have called me a fool and a visionary. If I had said there would be an income and an inheritance tax and a social security safety net for the old, poor, and disabled, most reasonable people would have said never.

But of course all those things happened and I think we can continue to surprise ourselves with what we can do under an Obama-Clinton administration. Just a thought.