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Archive for November, 2009

The Republicans have made a lot of political hay about “the massive” health care reform bills — comparing them to Tolstoy’s novel War and Peace, often cited as the world’s longest novel.  Once again, their political hay is full of little more than hot air.  It’s easy to expand something written by increasing the margins, enlarging the font and setting extra wide margins.  While that may make it easier to read, much like the large print books for visually challenged readers, those tricks don’t make it longer.  It just kills more trees.

The official version of the Senate’s health care bill has been printed in the Congressional Record.  It comes in at 208 pages — not over 2000!

A more accurate way of gauging the length of a written piece is to count words.  The House version of the health care reform bill comes in at just over 318,000 words;  the Senate bill is some 1500 words shorter.   As a matter of comparison, No Child Left Behind came in at 280,000 words.  Tolstoy’s War and Peace, depending upon which translation is used weighs in at a whopping 560,00 or even 670,000 words!

So, once again, the GOP leadership is using sleight of hand deception to create the image of big government.  Let’s be honest.  The conservatives would like nothing more than to see 100% of the federal budget used for defense.  All these regulations just get in their way.  And if that’s what you like, I would caution you to consider what has happened to our economy each and every time in our history when unfettered capitalism gained primacy.  The stock market crash of 1929, followed by a decade-long Great Depression; deregulation of the savings and loan industry, followed by its collapse in the early 1990s; and our current financial debacle.  The common causal thread in all of those events was a distaste for regulation and the inevitable greed that deregulation unleashed.

Republicans as a group seem to be plagued by short memories.  While ignorance of history might be understood (not forgiven, just understood), Dana Perino’s latest pronouncement takes the cake.  After demonstrating her ignorance of “ancient” history (apparently defined as anything prior to her birth) when she allowed as how she didn’t know about the Cuban Missile Crisis, she has topped that by stating on Fox News that there wasn’t a terrorist attack during George W. Bush’s term while condemning the Fort Hood attack as terrorism.  To be sure, 9/11 happened before she became Bush’s press secretary, but it cannot be denied as a seminal event of his presidency.  Pathetic.  Ignorant.

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How do you solve a problem like Afghanistan?  It’s a puzzlement.  On the one hand, Gen. McChrystal is asking for more troops.  Lots more troops.  Perhaps upwards of 40,000 more troops.  On the other hand, other voices are saying that more troops isn’t the right answer.  The pundits have, understandably, taken sides, too often shedding more heat than light.

The first thing to understand is that troop numbers (and other resource levels) represent the tactical level.  The president has said that he’s doing an in depth analysis of the situation in Afghanistan.  Expecting a decision on troop levels before that analysis is complete may be good for scoring political points, but it’s like looking through the wrong end of a telescope.  It’s starting at the wrong end of the discussion.  It’s beginning at the end and working back towards the beginning.

The beginning of the analysis is defining precisely how Afghanistan figures into the national interest of the United States.  And national interest includes more than simply national security.  It does (or should) include economic interest and other areas of concern.   If the current relationship with Afghanistan doesn’t contribute to our national interest, what are the ways in which it does not? That defines our strategy.  The answer to that question leads directly to a discussion of how best to improve that relationship.  That discussion, in turn, results in mission definition.  This analysis doesn’t happen in a day or even a week.  And it couldn’t be completed so long as the Afghan election results weren’t known.

Then, and only then, can decision-makers arrive at the appropriate resource levels.  It’s easy to assume that a goal of improving our national security leads automatically to a military solution.  But that’s a very simplistic answer and assumes that force is the only way we can wield power.  It also assumes that we have unlimited military resources at hand.

A second fact needs to be understood and factored into the public understanding.  The general in the field is looking at what he needs for his particular mission.  He doesn’t and shouldn’t concern himself with actual or potential needs in other parts of the world, or even if the military can field the requested numbers without putting other current or potential conflicts at risk.  Those are things that are the responsibility of the Joint Chiefs to consider in advising the Commander in Chief.

The President has said that our effort in Afghanistan is aimed largely at training an Afghan army so that the country can defend itself.   Yet, is that possible given that the country ranks second only to Somalia in corruption?  It can even be argued that Somalia lacks a government at all, and Karzai’s control doesn’t extend much beyond Kabul.  It’s neither irrational nor unpatriotic to argue that no amount of US support — military or otherwise — will change the situation in Afghanistan.  And yet, simply to pull out would be immediately attacked as being weak on defense.  So there are domestic political considerations to be weighed as well.

If the President decides to send more troops, as it appears he will, how many can he spare?  Our military is far smaller than it should be to fight two wars at the same time.  And even though we are disengaging in Iraq, our forces are exhausted.  Most have served multiple tours — some as many as five — already.  How much more can we ask of them?  We cannot ignore the long-term costs of these deployments on their minds and spirits as well as on their bodies.  Costs that go well beyond monetary ones.  There may well not be the number of troops available that the general is requesting.  One reason there have been so many contractors providing support services in Iraq is that our military is too small to allot the needed numbers to non-combat roles.  Do we need to re-institute the draft if we’re going to continue to fight in Iraq, Afghanistan and who-knows-where else?  That is a tactical question, but first we need to determine our  goals in that part of the world.

These are the sorts of questions and considerations that President Obama must address before making his decision.  His trips to Dover and to Arlington and to Fort Hood are part of his duty.  They are also a solemn reminder of the cost of war.  It is right that he understand that cost.  The cost of war should not be remote and impersonal.  It’s not a surprise that the military and diplomatic men on the ground have different views of how to “solve” the problem.  The former has been taught to advocate for a solution by force while the latter has been taught the potential benefits of so-called “soft power.”  Both have their place.  The question is which, or which mix, is the most likely to achieve the desired ends.

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A deliberately controversial public service announcement has been receiving air time on the Web.  In it, the viewer takes the role of the abuser, guiding blows to the woman’s face via his/her mouse.  The violence level of each blow is identified, until bruised and battered, the woman falls to the floor.  At that point, 100% IDIOT is displayed on the screen.  The spoken message, in Danish, is “break the silence.”

I have a very mixed response to this PSA.  I’ve been on the receiving end of such blows, so I understand the importance of breaking the code of silence and shame that accompanies domestic violence.  Yet, is this in your face approach the best way to make the point?

And let us not forget that there are other forms of abuse that are just as insidious, perhaps more so, than physical abuse.  When one is beaten, the bruises remind you of why you hurt.  But there are other injuries — those that result from verbal and emotional abuse.  Those don’t leave visible marks, but they result in scars just the same.  And because there are no obvious physical manifestations, it’s easy to minimize them, to ignore them and even to deny them.  I know I did.  For years.  Decades even.  I was more fortunate than many women.   During an active recovery period from years of alcoholism, my abuser was able to confront the issue with me and to take responsibility for his actions instead of continuing to blame me for everything that went wrong in our relationship.  But that didn’t make all the pain go away.  I still struggle with some of the emotional scars.    For years, I was told  that I was always wrong.  Eventually, I began to believe it.

Yes, ending the silence is essential.  Because the silence perpetuates the shame.  Shame that somehow we are responsible for the actions of another person.  I fully accept that my actions may on occasion provoke a negative emotional response.  However, I am responsible only for my actions and my words, not for those of another.  If another person chooses to respond inappropriately — with physical, verbal or emotional abuse — I am not responsible for his action or words.  Abuse comes in many forms, and it’s not ok.  Ever.

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One aspect of the health care discussion hasn’t gotten nearly enough attention.  This nation is woefully short of primary care physicians.  And, assuming something passes that brings at least some of those currently uninsured into the health care system, providing that care via primary care docs will be a huge challenge.  The reality is that doctors can make more money (and thus pay off the debts incurred during college and medical school) in a specialty rather than as a front line provider.  So, rather than leaving more people out of the system, let’s look at creative ways to encourage more medical students to go into internal medicine, family practice or general practice.

A generation ago, California lacked teachers to educate the baby boomers’ kids.  So, a policy was adopted to forgive 10% of a student’s debt (up to 50%) for every year they taught.  I benefited from that policy, as did thousands of other people.  Today, New York City has a program to pay for teachers’ masters programs if they teach in the inner city schools.  My niece’s daughter has a masters degree from Fordham University, courtesy of that program.  In the process, she gained experience as well as education, having taught two years in a Bill and Melinda Gates Foundation-sponsored school.  Why couldn’t we do something similar to encourage doctors to go into primary care?  The need is great, and there are a number of things we can do both immediately and in the long term.

Urgent care facilities:  Hospital emergency rooms are the most expensive option to obtain primary care.  Yet, many cities and towns have urgent care centers that are closed at night.  These are a lower cost option than the hospital emergency room.  Why open them at night and come up with a way to pay them to service the uninsured until we can get everyone covered?

Physician assistants and nurse practitioners: These professionals can provide routine care.  They need to be utilized to the maximum extent possible as front line providers.  While there are limitations in what they can do to provide care, their skills are not only adequate but appropriate for routine health care needs, freeing up physicians for those cases that require more detailed diagnosis and treatment.

Recently my husband spent about eight hours in the ER for a situation that required attention in the middle of the night but which was not life threatening.  We arrived at about 3 a.m., and like most ERs, it was busy and became busier once the sun came up.   Patients were stacked up waiting for a bed to clear, and during the wait, there were two and three EMTs for each patient who had to wait until their patient could be transferred from their gurney to a bed.

Here’s my proposal for immediate implementation:

Develop urgent care centers that work in concert with hospital ERs.  A triage process already exists to ensure that critical cases are seen ahead of non-emergency ones.  Those non-critical cases could be diverted to the urgent care facility.  And the urgent care centers could be staffed with physician assistants and nurse practitioners, with a physician available if needed.  The physicians there would not need to be emergency medicine doctors, as the cases seen there would have already been determined not to require that level of training.

In the mid-term range, if we lack sufficient PAs and nurse practitioners, a crash program could be initiated to increase their numbers.  Incentives to encourage people to enter this profession could come in the way of forgiveness of loans or even paying outright for their professional education, provided they commit to a given number of years of service — at prevailing wages.  It’s an investment in our health care future.

In the long term, the need for additional primary care doctors remains.  Yet, the same incentives outlined above could be used as incentive for doctors — albeit with a longer commitment of time.

Do we really need more plastic surgeons to do face lifts and breast implants?  I think not.

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My current Congressman is a conservative Republican… not so conservative that he falls into the wingnut category, but close.  I’m what someone called a faint blue light in a sea of red.  So I make a point to communicate with him fairly regularly, if only to remind him that he also represents people with views that don’t conform to his own.  And if I get any response, it’s a blanket canned one repeating all the GOP talking points.  It’s as if he doesn’t have an original thought in his head but simply responds out of obligation, using the same pre-recorded message to everyone.

My most recent communication was on health care.  I use the term recent rather loosely, because I had forgotten what I said.  After reading through the tirade on how we must protect the insurance industry from the inevitable collapse that would result from “government-run” health care — at least he’s gotten off the death panel bit — my blood pressure was rising, so I fired off a response.

I pointed out to him that when he first ran at least 5 terms ago, he promised to serve only 2 terms.   So much for that promise.  I also pointed out to him that he was already receiving government run health care as he is eligible for Medicare.  Whether he also uses one of the health insurance plans available to Congress and all other federal employees, he is automatically enrolled in Medicare Part A.  I challenged him to give up his government-funded, government-run health care programs.  Will he?  Certainly not!  So I asked how he figured he could in good conscience participate in something that he obviously didn’t think his constituents were worthy of.

I’ve probably had a wider range of experiences in the health care system than he has.  I benefited from the federal health care system for a number of years, thanks to my former husband’s employment as a civil servant.  I’ve had employer-provided health insurance (and paid my portion of the premiums).  I’ve been in the private insurance market, with its high-cost-low-benefit policies, been denied coverage, had coverage canceled after filing a claim, and been uninsured.  I have experienced first hand the limitations of “managed care” with its gatekeepers, limited choice of providers and the like.  And next year, my husband’s company has eliminated choice of plans altogether — there is one insurance plan for all employees.  In contrast to my own experiences, this summer I’ve seen how Medicare with a private supplemental policy works, thanks to my mother-in-law’s health crisis.

If I had a vote on health care reform, it would be Medicare Part E (for everyone).  It is a system that has been in operation for over a generation — i.e., no new bureaucracy and a proven track record.  Participants pay a monthly premium of about $100 and most supplement that with a secondary, private plan.  By bringing millions of additional people, many of them healthier than the senior population, into the system, per capita costs would automatically go down.  Everyone would be covered.  And the insurance companies would be able to sell those supplement policies to a huge pool of people.  Just as they do with the current Medicare supplements, insurance companies would compete with each other in that secondary market.

Medicare cannot refuse people because of a pre-existing condition — nor can the insurance companies who provide Medicare supplements.  And they cannot cancel your coverage when the bills start coming in.  Everyone 65 or older is included now.  Why not simply remove the age restrictions?

It is true that reimbursement rates for Medicare are lower than for other insurance plans.  But doctors would be able to streamline their administrative activities.  The bills would automatically go to CMS for payment.  Currently, doctors must maintain a billing department whose function is to deal with insurance companies — getting prior approval for treatment and fighting for payment afterward.  That cost of doing business would go away, more than making up for the reduced reimbursement rates.

Younger people argue that they are paying for the care of the elderly because their own medical costs are low.  True, UNLESS you get into an accident or contract an illness.  And if they do have a medical catastrophe, those who are uninsured can still get treatment.  If they can pay, they are generally bankrupted.  If not, the providers absorb the costs.  And those of us who are insured pay for the care of the uninsured — to the tune of about $1000 each per year in increased premium costs.  Every rational person admits that the current system isn’t working.  The challenge becomes how to have a real discussion — looking at what is best for the American people, rather than how to preserve campaign contributions.

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