One More Time….

The American Prospect sends out a regular newsletter, titled Kuttner on Tap, in which the author, Robert Kuttner, addresses a variety of issues.

Kuttner is a longtime journalist– currently a professor of social policy at Brandeis University.. He co-founded and co-edits The Prospect, which (according to Wikipedia) was created in 1990 as an “authoritative magazine of liberal ideas.” He is also a co-founder of the Economic Policy Institute.

Given Kuttner’s background, his preference for national health care is unsurprising, but a recent issue of the newsletter really resonated with me, not just because of stories like the one I shared last Friday, but because it mirrored my own experience with England’s National Health Service (NHS).

Kuttner was in London when he felt ill.

Yesterday, I had some odd health symptoms that suggested a visit to a doctor. This being Britain, off I went to the walk-in clinic of the nearest hospital of the National Health Service. What happened next is enough to make an American progressive weep.

I arrived at St Thomas’ Hospital, one of London’s busiest, at 10 a.m. By 10:20, I had been through a courteous triage process, filled out a basic form, and was scheduled with a GP. The doctor saw me at 11:00, took a history, examined me, performed a couple of tests right in his office, assured me that this was not serious, and shook my hand.

“Do I need to check out?” I asked.

“No, you are free to go,” he said. Less than 90 minutes after arriving, I was on my way.

Bill: zero.

As I said, this account mirrored a personal experience. A few years ago, my husband and I were on a cruise to England when he developed upper respiratory symptoms. By the time we got to Nottingham, where our oldest granddaughter was living at the time, he was really unwell, and she insisted we go to the nearby walk-in-clinic.

After a very brief wait, we were called back to the nurse practitioner. She took a history, examined him, and called an ambulance to take him to Nottingham University’s hospital. (She said she might be “over-reacting a bit–I hope so” but “better safe than sorry.”) The ambulance was there almost immediately, and I rode with him. I can’t say enough about how efficient and caring the EMTs in the ambulance were.

We were taken to A and E (Accident and Emergency). Again, we were impressed with the efficiency of the process; first, an evaluation and a number of lab tests, then further tests based upon the initial results. Throughout the (very long) day, personnel kept us informed of where we were in the process, and why they were doing what they were doing.

The fear was a pulmonary embolism; fortunately, the scans ruled that out. However, what the ship’s doctor had shrugged off as a cold or allergy turned out to be a heart problem that  hadn’t been detected by his cardiologist on his visit a week before our trip. The NHS doctor explained that his symptoms were the result of fluid accumulation–probably the result of unusual activity on the trip. He was admitted for a short stay so that they could eliminate the additional fluid.

Only when he was released were we asked whether we had insurance, since we weren’t British citizens. (The ultimate bill was $1900.–for all the tests, and a two day hospital stay. And Anthem–our insurer at the time–bitched about that and delayed payment.)

As Kuttner wrote,

NHS is far better, fairer, and more cost-effective than our system. Britain is a poorer country than the U.S. but has an average life expectancy almost four years longer (80.9 years to America’s 77.3).

Because the NHS is true social medicine with salaried doctors and nurses, the money and time wasted in the U.S. on parasite middlemen, coding and billing, rapacious insurance companies, hospital profit-maximization strategies, and excess lucrative procedures, is simply not a problem or a drain in Britain. All the money goes to patient care….

In this fiscal year, the entire NHS costs 152 billion pounds, or about $180 billion. That’s close to two-thirds of all of Britain’s spending on health care. By contrast, the U.S. spends a staggering $4.4 trillion.

Relative to GDP, Britain spends about 12 percent and covers everyone. We spend just under 20 percent, and tens of millions of Americans have no coverage while tens of millions more are woefully underinsured and must pay exorbitant sums or do without.

Other Western countries have other versions of national health care. All of them deliver better results for many more people for far fewer dollars.

It turns out that it’s very costly to refuse care to “undeserving” (i.e. under-resourced) people…..

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That Impervious Alternate Reality

I haven’t added what would be superfluous commentary to the news of Donald Trump’s overdue indictment. The media has already reported pretty much anything you might want to know about that indictment and the various reactions to it.

Did The Former Guy (TFG) break the law? Obviously. Were the potential consequences serious? Very definitely. (In fact, we have no way of knowing whether TFG actually sold or otherwise shared highly sensitive information with the oligarchs and autocrats he admired. Was that two billion dollar infusion of Saudi cash to Jared payment for information? Who knows?)

For those who reside in the real world, nothing in that indictment was a surprise–and despite TFG’s efforts to characterize it as politically motivated, it very clearly was not the product of a “witch hunt.”

What, then, is most troubling about this long-awaited legal confirmation that TFG is a crook? Why am I adding text to the millions of words being exchanged about this predictable indictment?

I’m commenting because I am absolutely gobsmacked by the reaction of the crazies who now constitute most of the GOP.

In the face of overwhelming evidence–much of it produced by Trump himself in his endless blatherings–you would expect partisans to simply shut up, or to defer to the operation of the legal system. Instead, those on the farthest edge are evidently calling for armed resistance, and elected officials are insisting that there is no difference between the inadvertent retention–and immediate surrender–of documents by Pence and Biden and Trump’s clearly intentional and deeply corrupt theft of national intelligence.

An article in the Intelligencer attempted to explain why Republicans will never admit Trump’s guilt.

Despite what you may have heard about the federal charges against Donald Trump, there is actually nothing shocking or unprecedented about a former head of state facing criminal charges. It has happened several times in other democracies, and it would have happened in the United States but for Gerald Ford pardoning Richard Nixon.

What is shocking, and carries the ominous reek of banana-republicanism, is the response by the opposition party to the news. Kevin McCarthy, the highest-ranking Republican leader, depicts the charges as a personal plot by Joe Biden — “It is unconscionable for a President to indict the leading candidate opposing him” — and a “grave injustice.” Trump’s leading Republican opponent denounces the charges as “political bias” and “the weaponization of federal law enforcement.”

Marjorie Taylor Greene likened Trump’s arrest to those of Jesus Christ and former South African President Nelson Mandela. Kari Lake–still insisting she won her election– threatened civil war.

Evidently, whenJonathan Chait wrote in the linked article that there is no conceivable set of facts that would permit the GOP to acknowledge Trump’s guilt, he knew whereof he wrote.

In the article, Chait traces what he calls the GOP’s “decades-long descent into paranoia,” a descent that has led to the “idiosyncratic embrace of a career criminal.”

Chait reminds us that the culture of today’s Republican Party was shaped by what Richard Hofstadter famously described as “the paranoid style” in American politics. Hofstadter was writing about a conservative movement that, at the time, was only a far-right fringe faction of the Party.. Today, as we know, that fringe has completely assumed control of the party– and Chait writes that it has imposed its “warped mentality” on half of America.

To its adherents, every incremental expansion of the welfare state is incipient communism, each new expansion of social liberalism the final death blow to family and church. Lurking behind these endless defeats, they discern a vast plot by shadowy elites.

As a result of that warped world-view, the party went in search of a strongman, someone who would “crush its enemies.” Chait writes that the GOP  could have found that strongman “in a politician, a general, a movie star, or an athlete. Instead, Republicans located their warlord in a crooked real-estate heir.”

It is the interplay of the two forces, the paranoia of the right and the seamy criminality of the right’s current champion, that has brought the party to this point. Trump’s endlessly repeated “witch hunt” meme blends together the mobster’s hatred of the FBI with the conservative’s fear of the bureaucrat. His loyalists have been trained to either deny any evidence of misconduct by their side or rationalize it as a necessary countermeasure against their enemies.

The concept of “crime” has been redefined in the conservative mind to mean activities by Democrats. They insist upon Trump’s innocence because they believe a Republican, axiomatically, cannot be a criminal.

I hope Chait is wrong about this paranoia infecting “half of America.” If it’s that widespread, we are in very deep do-do.

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Backlash

June is Pride Month. In my family, we take folding chairs and drinks to the sidewalk to watch the parade, and we cheer the participants as they go by. The parade gets longer every year. Over the years, it has also gotten more and more mainstream, with local businesses, politicians, schools, churches and synagogues joining the clubs, gay bars and civil liberties organizations.

I began attending the parade in 2002, when there were exactly 8 entries, the parade took 15 minutes, and most gay folks were still reluctant to come out of the closet. The speed of social change on issues of sexual orientation has been one of the bright spots in America’s quest for civic equality.

I suppose we should have expected the current, fierce backlash, but–like the backlash  to women’s rights explored in my recent book–it seems so unaware, so awkwardly out of place in a society that has moved on. Polling continues to confirm that these angry Christian “warriors” are a distinct minority, but thanks to the GOP’s success in electing radical right-wingers to state legislatures, anti-gay laws continue to be passed.

This year, activist haters targeted businesses supportive of Pride . (No pun intended.)

As Charles Blow recently wrote in the New York Times,

As the L.G.B.T.Q. community celebrates Pride Month, we are besieged by a malicious, coordinated legislative attack.

There’s been a notable rise in the number of anti-L.G.B.T.Q. bills since 2018, and that number has recently accelerated, with the 2023 state legislative year being the worst on record.

According to the Human Rights Campaign, in 2023 there have been more than 525 such bills introduced in 41 states, with more than 75 bills signed into law as of June 5. In Florida — the state that became known for its “Don’t Say Gay” law — just last month, Gov. Ron DeSantis signed legislation that banned gender transition care for minors and prohibited public school employees from asking children their preferred pronouns.

As Kelley Robinson, the president of the Human Rights Campaign, recently told me, the number of signed bills is likely to move higher: “There’s 12 more that are sitting on governors’ desks, so you could be at nearly 100 new restrictions on the L.G.B.T.Q.+ community by the end of this cycle.”

Blow compares the current legislative onslaught to the burning of a cross on a Black citizen’s lawn: an effort to frighten and cow a minority population. It is, as he says,  “a malicious, coordinated legislative attack.”

The 2023 state legislative year has arguably been the worst on record. According to HRC, this year there have been more than 525 anti-gay bills introduced in 41 states. As of June 5th, more than 75 have been signed into law, and that number is likely to increase.

The focus on trans children has been particularly despicable, since those children are incredibly vulnerable and least likely to be able to defend themselves. The decision to come after them was–quite obviously– strategic, as Blow points out.

It seems pretty obvious that the trans community is an attractive target for culture war bullies because it’s a small subset of the queer community and an even smaller subset of society as a whole.

According to a study last year by the Williams Institute at U.C.L.A., about 1.6 million people 13 or older in the United States, or 0.6 percent, identify as transgender.

Furthermore, in a 2021 survey, nearly 70 percent of Americans said they know a gay or lesbian person. Only about one in five said they know someone who is trans. That number is up but still small. That’s about the same number who said in response to a 2021 YouGov poll that they’ve seen a ghost.

Recognizing the roots of this particular backlash is critical to understand ing where it’s coming from–and where it wants to go– knowledge we need if we are to counter it successfully.

The war against trans children and the gay community generally is part of a hysterical  reaction to social change–a rejection of the improved status of Blacks, women and other previously marginalized communities. Today’s culture warriors are those who are–in William F. Buckley’s often-quoted description of conservatives– standing athwart history and yelling “stop”!

The party that was “conservative” in Buckley’s day has morphed into the party of pure bigotry in ours. A number of Democratic politicians–including the Mayor– participated in yesterday’s parade. Maybe I missed it, but I didn’t see a single Republican.

I did see huge contingents seemingly from every large local employer, and endless floats–from the police and fire departments, local schools and universities, civic organizations and LGBTQ clubs…and a crowd of thousands cheering and waving Rainbow flags. 

The immensity of that celebration doesn’t bode well for what has accurately been called the “slate of hate.”

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Speaking Of Punitive…

One of the cases the Supreme Court will decide this term is a lawsuit brought by Republican Attorneys General opposed to cancellation of a portion of student loan debt. Evidently, Indiana isn’t the only Red state with a despicable and arguably dishonest Attorney General, as a Brookings Institution study documents.

The AGs aren’t the only opponents of giving students some fiscal breathing room –the House of Representatives recently voted to repeal the program. But as Brookings  researchers write in the linked New York Times essay, the lawsuit  brought by six Republican-led states has received inadequate scrutiny.

So we decided to do the fact-checking ourselves. We filed public records requests and reviewed almost a thousand pages of internal financial documents, emails and other communications from the parties in the case, as well as court filings and the transcript of oral arguments at the Supreme Court in February.

We found that the states’ most fundamental justification for bringing the case — that canceling student loans could leave a Missouri-based loan authority unable to meet its financial obligations to the state — is false. As our research shows, and the loan authority’s own documents confirm, even with the new policy in place, its revenues from servicing loans will increase.

That this claim is manufactured–that it is a lie– is important.

Unlike legal systems that permit advisory opinions, in America, if there’s no injury, there’s no right to sue. The legal term is standing, and according to Brookings, the plaintiffs don’t have it. They simply said they did. (With our current Court–a Court that demonstrably privileges litigants with status and power –that may be enough.)

As the researchers note,

The ease with which the state attorneys general were able to make claims that contradict basic facts, void of any rigorous stress testing, is all the more striking when compared with the endless hoops that ordinary people have to jump through to prove their eligibility for financial aid or debt relief. This is what the sociologist Howard Becker calls the “hierarchy of credibility”: Those at the top of the social hierarchy don’t have to prove their claims; they’re just taken for granted. But claims made by those on the bottom are burdened by skepticism and demands for proof. In this instance, that difference may deprive millions of people of much-needed relief….

Compare that with the lengths that normal people must go to in order to prove they are eligible for debt relief. They have to submit mountains of documentation. Their claims are often denied for the most trivial of technicalities — a form filled out with green ink instead of black or blue, an electronic signature instead of an inked one.

Applicants for the older Public Service Loan Forgiveness program have to get paperwork signed from employers they had a decade ago. If a loan servicer transfers the account, the borrower may lose her payment history, and therefore her eligibility for relief. People who attended predatory for-profit colleges have had to submit extensive applications for relief, documenting their schools’ false allegations and misrepresentations. Even the Biden plan required an application.

The linked essay goes into detail, thoroughly debunking the damage claims that support plaintiffs’ standing, and I encourage you to click through and read that analysis. But I want to focus on a different–albeit related–question: what policy position does this dishonesty serve?

To put it another way, why are so many Americans–mostly but not exclusively Republicans–so opposed to relieving student debt?

In the final paragraph of the linked essay, the researchers write that an affirmation of the plaintiff’s claim would

effectively be confirming a fake plaintiff, false facts and an unjust claim. Falsehoods about falsehoods would be a hard way to lose the debt relief the president promised to 43 million Americans and their families. And a Supreme Court that doesn’t scrutinize basic facts would be a further disgrace for a body already plagued by scandal.

I’ve previously noted how punitive today’s GOP has become. Here in Indiana, we’ve seen our Attorney General wage a petty vendetta against a doctor who legally aborted a ten-year-old rape victim. We’ve seen legislators go out of their way to harm trans children and dismiss the very notion that women are entitled to bodily autonomy and effective health care.

Nationally, we’ve witnessed GOP efforts to punish the poorest Americans by curtailing social welfare programs (while protecting the rich against attempts to audit them or–gasp!–make them pay their fair share.)

American lawmakers used to argue about the “how”–what’s the most effective way to help this or that population, or solve this or that problem? But “how” has given way to “why”–why would we want to help the less fortunate?

When did the cruelty become the point?

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Fed Up Yet?

Americans are understandably distracted by the current cultural battles that are, at their base, efforts to halt the steady erosion of White Christian male privilege. I spend a fair amount of time analyzing and discussing those battles, and ignoring a much more substantial disagreement about what a society/country owes its members/citizens.

It’s the question inherent in that old Amex commercial proclaiming “membership has its privileges.” 

As I’ve noted previously, in the United States, the “privileges” of citizenship do not include health care or financial security. Our approach to social welfare has been and remains punitive–and as a result, the “systems” we’ve built incentivize greed over good works.

A recent report from the New York Times focused on the reality of America’s approach to health care.

Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.

But a wealthy nonprofit health system in the Midwest is among those taking things a step further: withholding care from patients who have unpaid medical bills.

Allina Health System, which runs more than 100 hospitals and clinics in Minnesota and Wisconsin and brings in $4 billion a year in revenue, sometimes rejects patients who are deep in debt, according to internal documents and interviews with doctors, nurses and patients.

Although Allina’s hospitals will treat anyone in emergency rooms, other services can be cut off for indebted patients, including children and those with chronic illnesses like diabetes and depression. Patients aren’t allowed back until they pay off their debt entirely.

Companies like Allina–theoretically “nonprofit”– get huge tax breaks for providing indigent care in their communities. An investigation by the Times  found that almost all  nonprofit hospitals have– for decades– fallen short of that charitable mission.

Allina cuts off patients who owe money for services received at any of its 90 clinics. Written policies instruct staff on how to cancel appointments for patients with at least $4,500 of unpaid debt– how to lock their electronic health records so that staff can’t schedule future appointments.

“These are the poorest patients who have the most severe medical problems,” said Matt Hoffman, an Allina primary care doctor in Vadnais Heights, Minn. “These are the patients that need our care the most.”

In 2020, less than half of 1 percent of Allina’s expenditures were for charity care, well below the pathetic national average of 2 percent for “nonprofit” hospitals, despite the fact that its annual profits since 2013 have ranged from $30 million to $380 million. In 2021, its president earned $3.5 million–and it recently built a $12 million conference center.

It’s estimated  that 100 million Americans have medical debts. Those debts make up approximately half of all the outstanding debt in the country, and are responsible for half of all personal bankruptcies.

Some 20 percent of hospitals nationwide have debt-collection policies that allow them to cancel care. The most expensive “health care system” in the world doesn’t seem very focused on health.

Then, of course, there’s what Jamelle Bouie calls a “twisted view” of the social safety net, most recently illustrated by the GOP’s insistence on work requirements for SNAP and Medicaid beneficiaries. 

As Bouie notes, there’s plenty of evidence that work requirements don’t lead to more employment–that their only effect has been a loss of benefits by poor Americans.

Work requirements don’t work, but Republicans still want them, so much so that they threatened to crash the global economy to get them. Why? The obvious answer is that work requirements are an effective way to cut programs without actually cutting them. With a little extra paperwork and another layer of bureaucracy, states can keep thousands of people who qualify from getting access to benefits.

To add insult to injury, It cost states tens of millions of dollars to implement work requirements. In Arkansas, for example, implementation cost close to $26 million; in  Iowa, the cost of administering the new rules was $17 million over three years — far more than the state would have spent on SNAP during that period.

We keep hearing that America is the richest country in the world. Not only could we afford to be less punitive to the people who most need a hand up, we could actually save money in the process. Tax dollars already pay some 70% of the country’s medical costs, and those dollars would probably cover 100% if CEOs weren’t overcompensated and we saved health insurer overhead.

I’ve previously argued that a Universal Basic Income would solve significant social problems– Whatever the pros and cons of a more expansive, less punitive view of “membership,” stories like these should remind us of the multiple deficits of what passes for current health and welfare policies in “rich” America.

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