Prescriptions from the Doctor

It’s interesting that most of the public opposition to the Affordable Care Act has come from politicians–not infrequently, from politicians whose most generous donors have a vested interest in the medical status quo–and not from providers of medical care.

Perhaps we should listen to the people on the front lines–the doctors. This is from my cousin, a cardiologist whom I often quote here:

As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely sustained them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during those so-called “golden years.”

Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. The financial burden was lifted from both the patients and us physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival.

He writes that two other doctors have recently weighed in via the New England Journal of Medicine (November 20, 2014). In “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” C. van der Horst, MD, wrote that, when he anticipated passage of the Affordable Care Act, he thought he would no longer need to worry about patients’ affording necessary medications, preventive care services and hospitalizations.

But then van der Horst’s home State of North Carolina (like Indiana) blocked Medicaid expansion (even though, as it bears repeating, the federal government would pay 100% of the costs for the first 3 years and 90% thereafter). Over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina lawmakers have stubbornly refused to expand coverage.

The second article–written by Michael Stillman, MD–detailed the very different experience of Kentucky. Kentucky approved Medicaid expansion and “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay” and giving 650,000 Kentuckians access to decent, comprehensive medical care. Most had previously lacked health insurance, had avoided routine preventive care—and worried that a medical emergency would leave them bankrupt. Medicaid expansion lightened their financial and emotional burden–and as a bonus, provided better physician education.  (Previously, doctors in training had become accustomed to offering substandard and incomplete care to indigent populations.) Now they are able to provide appropriate, evidence-based care.

As my cousin concludes:

This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under-served.

Listen to the doctor.

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Let It (All Hang) Out

Our sorry excuse for a newspaper has a feature–common to many papers–called “Let It Out,” where readers can comment on the news of the day. I generally scan it, despite the relative absence of anything that might be considered insightful, since it is one of the few features (especially at this time of year) that isn’t an ad.

Yesterday, there was a particularly smug, utterly clueless sentiment about the mess in Ferguson: if African-American parents are concerned about what to tell their children about interactions with the police, the reader wrote, they should just tell their sons to obey the law, and then they won’t have any problems.

Really?

I guess all those statistics about disparate law enforcement are irrelevant. (Driving while black, anyone?) I guess the disclosures by Anonymous (the internet hackers who took over the Klan’s twitter account a couple of weeks ago, and found KKK members among police in several cities) are just evidence that cops are jolly joiners. And all those personal stories in the newspapers and on our Facebook feeds? Just anecdotal; ignore them.

Let’s get real, as the kids might say, and concede that none of us–on the left or right–knows what happened before Michael Brown was shot six times. The exoneration of the police officer in this particular case–irregular as the Grand Jury proceedings evidently were–may have been totally justified. And nothing excuses rioting and the destruction of the property of innocent shopkeepers.

Nothing excuses wholesale condemnation of the police, either. I teach a required course in a school with a well-regarded criminal justice program, so I teach a lot of police officers. Most of them are genuine public servants, trying to do a difficult but necessary job that sometimes requires them to make split-second decisions.

All that said, it takes a special kind of intentional blindness to ignore the fact that there are some very bad apples drawn to a line of work that confers power over others. (When I was in City Hall, we tried to weed those people out with psychological exams, with spotty success.) It takes a perverse and selective understanding of the American landscape to ignore the extent to which racism still characterizes the experience of the black community, and to ignore the reasons why some members of that community might periodically explode with anger.

And it takes an offensive and deliberate moral arrogance to lecture mothers who are desperate to protect their children from encounters that every sentient American knows are far from rare.

When you “Let it Out,” what comes out can sometimes be pretty horrifying.

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If It Walks Like a Duck, Call it a Turtle

A couple of weeks ago, Catherine Rampell had a must-read column in the Washington Post, beginning with “Don’t tax you, don’t tax me. Tax that feller behind the tree!”

Rampell focused upon the rampant hypocrisy of the “no tax” ideologues:

Jonathan Gruber has been vilified for (among other things) noting the “tortured” way that sections of the Affordable Care Act were written in order to stay in the good graces of both the Congressional Budget Office and the public. But such budgetary gamesmanship has long been an open, and bipartisan, tactic in Washington. When “spending” became a dirty word, Congress phased out earmarks. In their place, it doled out treats to special interests through the tax code, now awarding more than a trillion dollars each year in federal tax breaks, carve-outs and loopholes. Arithmetically, letting someone pay less in taxes is identical to spending money on them, but voters don’t see things that way….

Voters hate taxes and will punish any politician who threatens to raise them (or, in many cases, does not accede to cutting them). But schools, roads, police forces, garbage collection, firefighters, jails and pensions still cost money, even when you cut them back as much as voters will tolerate. So instead of raising taxes, state and municipal governments have resorted to nickel-and-diming constituents through other kinds of piecemeal, non-tax revenue raisers, an outcome that is less transparent, and likely to worsen the economy, inequality and social injustice.

Examples abound. Call it a toll. Call it a fee. Finance local government with smoke and mirrors.

This “no tax” chicanery plays to our worst impulses, the “I’ve got mine, Jack, and piss on the public good” attitudes that have crippled efforts to improve our communities and build a more inclusive, robust public square. But as intellectually dishonest as the “that’s not really a tax” strategies are, they’re a subset of a larger, even more troubling phenomenon: we’ve stripped our language of content.

I’ve frequently noted–in response to overheated rhetoric from the Right–that President Obama really can’t be both a socialist and a Nazi, because those words have meanings, and they are different. (And actually, in a sane world, neither remotely applies to the President, whether you like his policies or hate them.) Science is not a system of “beliefs” equivalent to religion, because falsifiable empirical facts are not matters of “faith.” LGBT folks don’t have “lifestyles,” they have orientations. I could go on and on.

The problem with misuse and abuse of language is that we lose the ability to communicate with each other. When words no longer have generally accepted meanings, we are just making sounds–and when those words are turned into epithets and insults, intelligible conversation comes to a screeching halt.

Language is one of the most important achievements of the human race; it is fundamental to human progress. We jeopardize more than we realize when we debase it.

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Happy Thanksgiving from the Gratitude Nazi

My children call me the “gratitude Nazi” because each Thanksgiving, I insist we take some time–before tucking into the turkey–to consider how fortunate we are.

In this blog, I tend to focus on things that distress me, or make me angry (or–increasingly–despondent). On Thanksgiving, however, it’s appropriate to reflect on how much I have to be grateful for.

I’m an incredibly lucky person. I have an intellectually-stimulating job I thoroughly enjoy, a loving and supportive (okay, forbearing!) husband, wonderful children (both biological and acquired), perfect grandchildren and longtime good friends. I’m also not ALICE, for which I am deeply grateful.

I’m privileged, and I know it.

I’m conscious of all my good fortune, but today, I especially want to acknowledge the gratitude I feel for the little community that has developed in the comments section of this blog. It has been a totally unexpected benefit of my foray into cyber “venting,” and one that I have come to value very highly.

I know only two or three of you from the “real world.” The rest of you I know only from our interactions here. I have learned so much from your thoughtful comments, suggestions and reactions, from the sharing of different perspectives, and most of all from the evidence your presence has provided that civil, constructive discussion of even very difficult and sensitive issues is both possible and enlightening.

I am very grateful for all of you who visit and help me make sense of the tumultuous world within which we must all make our ways.

Happy Turkey Day!

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Meet Alice

I have a friend who owns a major company, and I periodically receive his company newsletter. He’s a truly good person, philanthropic and civic-minded, so I was startled to read what was surely a throwaway line in the most recent newsletter, in which he wrote that his company had experienced a good year, despite the national administration’s policies favoring “lazy” Americans.

Shades of Mike Pence’s “ennobling” and Mitt Romney’s 47%!

These attitudes toward “the least of us” have long been an indelible part of American culture. When I was doing research for my book God and Country, I traced several ostensibly secular policy preferences back to their religious roots. In the case of poverty policies, I concluded that attitudes toward the poor (beginning with 15th Century English poor laws that forbid giving “alms to the sturdy beggar”) are rooted in a simplified Calvinism: worldly success signals God’s approval; poverty is evidence of moral defect. Originally doctrinal, these attitudes have been absorbed into the popular culture.

The problem is, this easy dismissal of struggling Americans is at odds with reality.

Recently, the United Ways of Indiana took a hard look at “Alice.” Alice is an acronym for Asset Limited, Income Constrained, Employed; it applies to households with income above the federal poverty level, but below the actual, basic cost of living. The report is eye-opening.

Here are some “highlights” (highlights being something of a misnomer here):

  • More than one in three Hoosier households cannot afford the basics of housing, food, health care and transportation, despite working hard.
  • In Indiana, 37% of households live below the Alice threshold, with some 14% below the poverty level and another 23% above poverty but below the cost of living.
  • These families and individuals have jobs, and many do not qualify for social services or support.
  • The jobs they are filling are critically important to Hoosier communities. These are our child care workers, laborers, movers, home health aides, heavy truck drivers, store clerks, repair workers and office assistants—yet they are unsure if they’ll be able to put dinner on the table each night.

For families living on the edge, families struggling just to put that dinner on the table, saving money is a pipe dream. There is nothing left to save. So these families are vulnerable to any unexpected expense—a car repair, an uninsured illness, even an unexpectedly high utility bill can be enough to plunge them into debt or worse.

The United Way report (which is available online) is intended as an educational tool. Its data rebuts the thoughtless but ingrained caricature so skillfully deployed by President Ronald Reagan: that of the “welfare queen.” Built into that dismissive shorthand is the assumption that poor Americans “play the system,” refuse to work, and spend their days taking advantage of hard-working taxpayers.

A few such people undoubtedly exist, but so do the “captains of industry” who “play the system” by lobbying for subsidies and favorable tax treatment, and companies like Walmart that protect their hefty profits by using the taxpayer-provided safety net to supplement their payment of poverty wages.

Most businesses aren’t like Walmart; most owners are hardworking and honest, just as most Americans who fall below the Alice threshold are hardworking and honest.

As the Executive Director of the Jennings County Economic Development Commission wrote in the introduction to the report:

Alice is the family in Elkhart whose car breaks down, which takes the grocery money, which sends the family to the food pantry. Alice is the family in Terre Haute whose entire economic life comes undone when the breadwinner breaks a leg and loses three weeks wages. Alice is the family in Marion whose 11-year-old watches the 5-year-old because they can’t afford afterschool programs despite both parents working full-time.

Dismissing Alice as lazy is lazy thinking.

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